Questionnaire

THE OCEAN REHAB

......serenity at its best!!

Contact Questionnaire

It is FREE to fill out the Contact Questionnaire below. The answers will let us know a little bit about you as well as how we may best be able to help you.

Please submit your Contact Questionnaire by clicking on the button that reads "Submit." We will get back in contact with you as soon as possible, within 24 hours to discuss your treatment needs. ( If you are not contacted, please respond to SavitchRecovery@aol.com )

There is no obligation for submitting this Contact Questionnaire; however please note that no reservations at the Ocean Rehab will be confirmed by filling out and submitting this form. Please note: no fees will be accepted at this time as certain dates have already been reserved in advanced.

* Required fields
Name *
E-mail Address *
Do you speak and understand English? *
2. Vital statistics: Date of birth/ height/weight/occupation/marital status/children/address/phone *
3. Any medical problems? Which ones? Any allergies?(food,pets,meds) *
4. Any medications? Which ones? How long have you been taking these medications? Why do you take these meds?
5. Any mobility problems or physical limitations? Describe. *
6. Any psychiatric problems? Describe, including hospitalizations. *
7. What treatment (rehab/detox) have you had in the past? Completed? Also, what is your substance abuse problem? (i.e. which drugs, alcohol??) Describe in detail. *
8. If you have had treatment in the past, what problems have you encountered in maintaining sobriety or staying drug free?(If no previous treatment, type "N/A")
9. If accepted into the program, do you have the necessary financial resources? *
10. How long a program will you be able to commit to? *
11. Do you have a valid passport? *
12. What are your hobbies/recreational activities/spare time activities?
13. Do you have any special dietary needs/allergies/preferences? Describe.
14. What is the requested date of admission? *
15. What is the airport city you would be flying from? What other airports are nearby? *
16. Are there any special needs or requests?
17. How did you hear about us? *
18. Any questions? Please ask.

If accepted for admission, a deposit will be requested to guarantee your spot. Remember we are not a 'factory' recovery center. There are no more than 12 clients at any one particular time.

Drug and alcohol addiction treatment in a holistic environment on the beach, The Ocean Rehab can be reached 24/7 Toll-free at 954-993-5635. Chronic relapse or dual diagnosis account for a high number of clients. Men and women from all walks of life and all lifestyles are treated in a caring and knowledgeable manner.Our detox associates in the U.S.A. are available for a no obligation consultation. Content of this entire website is held under the copyright laws of the U.S.A. and all recognized international treaties as shall apply. Copyright: 2008 - Update March 2011. All rights reserved.