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.

Confidential Online Assessment

Note: all information submitted will be kept strictly confidential.

Contact Information *Denotes Required Fields
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Last Name:
E-mail Address:	*
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You are contacting Support Systems Homes for:		Self Family Member Husband Wife Friend Employee Patient Client Other
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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?
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

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.

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

· Alcoholism
· Heroin Addiction
· Methamphetamine
· Cocaine Addiction
· Marijuana Addiction
· Prescription Drugs
· Hallucinogens
· Inhalants
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Support Systems drug rehabilitation and substance abuse treatment programs provide comprehensive services for recovery from drug addiction and alcohol abuse, Offering national drug and alcohol rehab, sober living, residential treatment, detox, day and outpatient programs based in San Jose, Northern California.
www.drug-rehabilitation.com

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Drug Rehabilitation and Substance Abuse Treatment at Support Systems

Confidential Online Assessment

Contact Information

Drug and Alcohol History

Treatment History

Medical History

Additional Info