Eagles Nest
Rehab Center

Please fill out this information form.
All the information provided is held in strict confidence.
We will assist you in achieving complete rehabilitation.

Your Name:
Email :
Home Phone #:
Cell Phone #:
Work Phone #:
State/Province:
Addict's First Name:
Drug of Choice #1
Drug of Choice #2
Is Addict seeking help?
 
List any Drug rehab programs previously attended and if treatment was completed
 
Add any other information regarding Drug Rehab Programs previously done
 
Describe any medication history past or present (Name,Length, dosage etc)
 
Describe addicted person's history (hospitalizations, psychiatric evaluations,
present illnesses etc)
 
Describe addicted person's legal history. (current & past charges or incarceration)
 
Any questions or comments regarding drug rehabs
 
What search engine did you use to find us?
 
What Keyword(s) did you put in?