Hello,

You have been identified as a possible participant in a research study about online addiction treatment-seeking and perceptions of recovery. Participation in this study will be completed entirely online and you can earn up to $90 for participating.

If you are interested in participating, please press the "Continue" button below to allow us to determine whether you qualify, otherwise you may press the "No Thank You" button and you will next be directed to you RehabFinder search results.
  Your choice will have no effect on any aspect of treatment you may be seeking.

Thank you for taking the time to consider participating in our study.


No Thank You
Continue
Rehab FinderCall Us: 1-323-592-9591

Please fill out the form below. We understand the sensitive nature of some of the questions, so feel free to skip questions that make you uncomfortable. However, please know that the more information we have, the better your treatment recommendations will be.

Registered users can receive more such search results, Sign up here to receive twice as many results.

General Information

1.Is the treatment sought for caller or someone else?
  Self Other
2.Client's zip code
   
3.What is the client's ethnicity/race? (Check all that apply)
  White Black/African American American Indian/Alaskan Native
  Asian Spanish/Hispanic/Lation Pacific Islander/Hawaiian
  Spanish is primary language  
4.Client's gender
  Male Female
5.Client's Age
 
6.Does the client observe any religions? (select all)
 
None Catholic Anglican Protestant Mormon Jewish Muslim Other - Specify
7.Where are you living at the moment?
 
8.Is the client currently employed?
 
Full-time Part-time Unemployed
9.Client's sexual orientation:
 
Straight Gay Bi-sexual
10.Is this search related to an ongoing criminal offense or a recent conviction?
 
Yes No

Payment/Insurance

11.Health insurance?
 
Yes No Information on Access to Recovery Voucher program
12.Maximum monetary personal contribution to treatment per month
  $ (Amounts lower than $5000 will give preference to publicly-funded treatment that includes payment assistance while amounts greater than $5000 give preference to private treatment providers).

Addiction Specific

13.What is the specific addiction that requires treatment? (Check all that apply)
 
Alcohol Drugs Sex
Gambling Food
 
14.If the respondent is currently using, which drugs?
  Check all that apply. Indicate frequency, quantity (dollars spent per month, or equivalent street value), days of use in the past 30 days, and # of months of heavy use for all applicable drugs.
 
  Substance Frequency Quantity/
month
Days use
past 30
Months of daily or
near daily use
Alcohol Daily Several times/week Weekly Monthly $
Heroin/Other opiates Daily Several times/week Weekly Monthly $
Cocaine/crack Daily Several times/week Weekly Monthly $
Amphetamines/Meth Daily Several times/week Weekly Monthly $
Marijuana Daily Several times/week Weekly Monthly $
Hallucinogens Daily Several times/week Weekly Monthly $
Inhalants Daily Several times/week Weekly Monthly $
Prescription meds Daily Several times/week Weekly Monthly $
15.Ever injected drugs?
  Yes No
16.How many times has the client tried addiction treatment before?
 

Mental Health

17.Does the client suffer from any other mental health issues?
  Yes No
Acceptance of Terms : I have read, understand and accept AllAboutAddiction.com's Terms of use