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Drug Rehabilitation and Substance Abuse Treatment at Support Systems

Support Systems is here to help. If you would like to receive a call from our knowledgeable support staff, please complete the form below. We strive to provide treatment and/or appropriate referrals to all in need. The assessment process is confidential and free of charge.


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Confidential Online Assessment

Note: all information submitted will be kept strictly confidential.

Contact Information

*Denotes Required Fields

First Name:
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Last Name:

 
E-mail Address:

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Phone Number:

 
Alternate Phone:

 
State:

 
You are contacting Support Systems Homes for:   Self
Family Member
Husband
Wife
Friend
Employee
Patient
Client
Other
If Contacting Support Systems Homes  For Someone Other Than Yourself, Please Enter Their Name:

 
Select Your Time Zone:

 
Best Time To Call:

 
     

Drug and Alcohol History

 
What Is The Primary Drug of Abuse?

    		 
Method of Intake?

 
What Is The Secondary Drug of Abuse?

  		 
Method of Intake?

 
At What Age Did The User First Take Drugs?

 
How Old Is The User Now?

 
At What Age Did The User's Life Begin To Be Unmanageable?

 
Presently What Are The Resulting Problems of The User's Addiction?   drug rehabilitation centers
What Is The Family's Attitude Toward The User's Addiction?  
Does The User Admit To Having A Problem?

   yes  no 
Does the user want help?

     yes  no
     

Treatment History

 
How Many Times Has This User Been In Treatment for Their Addiction?

  
How Many of These Involved The 12-Step (AA/NA Model) Approach To Recovery?

  
Was There Any Success With Any Of These Treatment Episodes, and if so, what was the length of sobriety achieved?

  
     

Medical History

 
Does The User Have Any Known Medical Conditions?

  
If So, Please List The Condition(s) And Any Necessary Details:

  
Has This Person Ever Been Diagnosed With Any Psychiatric Disorders?

 
If so, is He / She Currently On Medication for A Psychiatric Disorder?

 
If So, Please Specify Medications Taken:

  
Does The User Have Medical Insurance?

  
If so, who is the Insurance Carrier?
  
     

Additional Info
Does The User Have Legal Issues?

  
If So, Please Describe

  
Please Provide Us With Any Other Information and Any Questions You May Have In The Area Below  
     
     

 

SERVING CONTRA COSTA COUNTY | SOLANO COUNTY | SAN JOSE
SAN FRANCISCO | MONTEREY COUNTY
 
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At Support Systems Homes, we believe the most important person is you. Support Systems now has 24 hour live assistance available. Call (800) 811-1800 and press 7 for after-hours admissions info.

drug rehab program description
Click Here to download and view the Support Systems Program Description in a convenient, printable format. (PDF)

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