Complete the Form Below to Receive a Call from One of Our Qualified Addiction Specialists!


If you want to beat addiction and improve your quality of life, now’s the time to start. Simply complete the electronic assessment questionnaire below and a qualified addiction specialist from Caron Drug & Alcohol Treatment Centers, one of the nation's leading rehabilitation facilities, will contact you within 24-72 hours. He or she will provide you with the options you need to get the help you need as soon as possible. Our goal is to provide you with the information necessary to make an informed decision on the best course of treatment for you or your loved one, and the best facility to meet your needs. Together we can conquer addiction — for life!

First Name: (*)

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Last name: (*)

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Email Address: (*)

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Phone Number:

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Alternative Phone:

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State: (*)
Choose OptionAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
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If Contacting For Someone Else Please Provide Their Name:

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Time Zone:
Choose OptionPacificMountainCentralEastern*Other
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Preferred Contact Method:
Choose OptionPhoneEmail
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Best Time to Call:

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Drugs Being Used: (*)
Alcohol
Cocaine
Crack
Heroin
Methamphetamine
GHB
Ecstasy
Inhalants
Ketamine
Prescription Pain Killers (Morphine, OxyContin, Vicodin, Fentanyl)
Prescription Benzodiazepines (Xanax, Klonopin, Valium, etc.)
PCP
Marijuana
Methadone
LSD
Other Drug
Eating Disorder (Anorexia, Bulimia, Binge Eating, Overeating)
Other Addiction (Sexual Addiction, Gambling Addiction)

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Drug History

At What Age Did The User First Take Drugs?

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Whats the user current age?

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Problems Caused By Addiction:

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Family Attitude Towards Addiction:

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Does User Admit Problem?
Choose OptionYesNoNot Sure
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Does User want Help?
Choose OptionYesNoNot Sure
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Is User Willing To Leave Home?
Choose OptionYesNoNot Sure
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Medical History

Has User Been Diagnosed With Health Problems?
Choose OptionYesNoNot Sure
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If Yes, Please List The Conditions And Any Necessary Details:

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Does The User Have Medical Insurance?
Choose OptionYesNoNot Sure
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If Yes, Please Select The Type of Insurance The User Has:
Choose OptionPrivate PPO InsurancePrivate HMO InsuranceMedicareMedicaidTricare(Military)OtherNot Sure
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Does The User Have Legal Issues?
Choose OptionYesNoNot Sure
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If Yes, Please Describe:

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Additional Information:

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By completing this assessment form and clicking “submit,” I agree to give Behavioral Health Central (BHC) permission to share the personal information I provided herein with Caron Treatment Center. I understand that I will receive a phone call from a member of the Caron Treatment Center within 24-72 hours of submitting this form and will be advised on treatment options. BHC, its partners, agents, suppliers and/or affiliates are not responsible for the information I receive and I assume all risk with respect to its use. Under no circumstances shall BHC, nor its affiliates, agents and/or suppliers be liable for any damages, including without limitation, direct, indirect, incidental, special, punitive, consequential or other damages (including without limitation lost profits, lost revenues, or similar economic loss), whether in contract, tort or otherwise, arising out of the use of or inability to use the information provided, even if BHC is advised of the possibility thereof, nor for any claim by a third party.

Agree To Terms (*)
I agree
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