Free · Confidential · About 5 minutes

Confidential rehab and addiction assessment

Answer a few questions about yourself or someone you care about. You will get an indication of how serious things may be and how soon to seek care, with clear next steps.

Step 1 of 20

First, a few details

So our team can follow up with you personally if you would like support. Your answers are only seen by our clinical intake team.

Full name *

Phone *

Email *

City or town *

I agree to The Sanctuary Retreat contacting me about this assessment.

Your information is kept strictly confidential and used only to respond to your enquiry. We never share it without your consent.

1. Who are you seeking help for?

Myself My partner or spouse My son or daughter Another family member A friend or colleague

2. How old is the person who needs support?

Under 18 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 or older

3. What are you concerned about?

Choose any that apply.

Alcohol Methamphetamine (ice, speed) Opioids or heroin Prescription medication (e.g. benzodiazepines, painkillers) Cocaine Cannabis Gambling Other substance or behaviour

4. How long has this been a problem?

Less than 6 months 6 to 12 months 1 to 3 years More than 3 years

5. How often does the drinking, drug use or behaviour happen?

Less than once a week Once or twice a week Most days Every day or several times a day

6. Has it increased over the last few months?

No, it has stayed the same or reduced A little A lot

7. Have there been attempts to cut down or stop that did not last?

No Once or twice Many times

8. Are there withdrawal symptoms when stopping or cutting down?

For example shaking, sweating, anxiety, nausea, trouble sleeping.

No Not sure Yes, mild Yes, severe Seizures, hallucinations or confusion

9. Has there been any previous treatment or assessment?

No, this is the first time GP or counselling only Detox or rehab once Detox or rehab more than once

10. How much is it affecting work, study or daily responsibilities?

Not at all A little Significantly Job or study has been lost

11. How much is it affecting relationships and family?

Not at all Some tension Serious conflict Relationships have broken down

12. Have there been any physical health effects?

None that I know of Some health concerns A hospital or emergency visit in the last year An overdose in the last 12 months

13. Is there also anxiety, depression or another mental health concern?

No Sometimes Yes, often Yes, a diagnosed condition

14. In the past month, have there been thoughts of self-harm or suicide?

If someone is in immediate danger, call 000 now.

No Not sure Yes

15. Are there legal or financial problems connected to it?

No Some Serious

16. How much support is there at home?

Strong support Some support Little or no support

17. How ready is the person to get help?

Ready now Thinking about it Not sure Not ready yet

18. When would you like support to start?

As soon as possible Within the next month In the next few months Just exploring options

19. Is there anything else you would like us to know?

Optional.

This self-assessment is a guide only. It is not a diagnosis or a substitute for advice from a doctor or qualified health professional. In an emergency call 000.