Drug and alcohol addiction and dependency treatment advice

If you are not the client it may be difficult to answer accurately some of the below questions, please just answer them to the best of your ability.

The more information that you provide, the more able we will be to assist you.

Are you?

Your Name & Relationship to Client

Client's Name

Client's Age

Client's Gender

Client's Home Town/County

Is the problem drugs or alcohol?

Which alcohol or substance is involved?

Pattern of use

Quantity used per day

Length of time drinking/using

Do you (the client) suffer from tremors, sweats, shakes, memory loss, anxiety, paranoia or depression?	Please provide additional details..

Is there a family history of alcohol abuse, drug addiction or depression?	Please provide additional details..

Do you (the client) lie about the quantity or the frequency of use?

Have you (the client) encountered any legal problems due to drink or drugs?	Please provide additional details..

Do you (the client) have a treatment budget in mind?**

Do you (the client) have private medical insurance?	Which insurer?

Have you (the client) lost a job through your use?	If yes, additional details..

Have you (the client) lost a close relationship through your use?

Have you ever lost your driving licence?

How would you (the client) like to receive treatment options?

Would you (the client) be happy to receive details from suitable treatment clinics?

How did you hear about Steps2Rehab?

'Phone number convenient for us to contact you/the client. (We will only call you if you request a call or if we experience problems with your email address).

Email address convenient for us to contact you/the client.

Mobile number for text contact

Please indicate if you would like a call back and advise us of the best time to call.	What time would you like us to call? Morning (9am - 12pm) Lunchtime (12pm - 2pm) Afternoon (2pm - 5pm) Evening (5pm - 7pm) Anytime / ASAP Which number would you like to be contacted on?

Any other information that might assist us to help you?

We aim to reply within 4 hours. If you have not heard back from us within 24 hours it is likely that there is a problem with your email address or telephone number. Please email mail@steps2rehab.com or call 0845 021 0777 or text 0779 099 1076.

** Please state accurately so we can provide you with a range of suitable options.