Verify Your
Insurance
Call Today!
866-294-9331
Menu
About Us
Our Approach
Our Guarantee
Our Team
Our Facilities
Treatment Programs
Our “Reclaim Your Life” Program
Drug & Alcohol Detox Program
Men’s Inpatient Treatment Program
Women’s Inpatient Treatment Program
Outpatient Treatment Programs
Lifetime Alumni Program
Recovery Services
Telehealth IOP
Naturopathic Therapies
Individual Counseling
Group Therapy
Family Education
12-Step Principles
Co-Occurring Disorders
Special Tracks
Substance Abuse
Alcohol
Cocaine
Methamphetamine
Heroin
Opioids
Benzodiazepines
Psychedelics
Marijuana
Prescription Drugs
Methadone
Admissions
Getting Started
Insurance
Resources
Addiction Blog
FAQs
Testimonial
Careers
Professional Insights
Contact Us
Arizona City
Gilbert
Phoenix
Tucson
Product
was added to your cart
Cart
Verify Your Insurance
Apply Online
Professional Preassessments (Alcohol Abuse)
Name:
*
(At least your first name is required)
Email Address:
*
Phone Number:
*
Are you unhappy with the way your life is going?:
Yes
No
Do you feel you may have a problem with alcohol?:
Yes
No
Are you preoccupied with thoughts of drinking?:
Yes
No
Can you stop drinking after one glass?:
Yes
No
Do you drink alone?:
Yes
No
Is drinking affecting your reputation?:
Yes
No
Is drinking causing problems with your job?:
Yes
No
Have your relationships been negatively affected?:
Yes
No
Do you refuse to go places where you cannot drink?:
Yes
No
Do you need to drink to have fun socially?:
Yes
No
Is drinking causing you financial difficulties?:
Yes
No
Do you hide alcohol from family or friends?:
Yes
No
Do you lie about your drinking?:
Yes
No
Do you drink to escape your problems?:
Yes
No
Do you drink to overcome shyness with other people?:
Yes
No
Has alcohol resulted in legal problems (DUI/DWI)?:
Yes
No
Do you worry that friends or family know you drink?:
Yes
No
Do you have memory loss from drinking?:
Yes
No
Do you ever crave alcohol?:
Yes
No
Do you drink to cope with fear or anger or depression?:
Yes
No
Are you willing and able to get treatment at The River Source?:
Yes
No
Menu
Your Name
*
Your Phone Number
*
I Am Applying For:
*
Myself
Loved One
If Applying for a Loved One, What is Your Loved One’s Name?
Have You Spoken to a Member of Our Admissions Team Yet?
*
Yes
No
Form Title
Page URL
CLOSE
Full Name
*
Phone Number
*
Email Address
*
How Can We Help?
*
Form Title
Page URL
CAPTCHA
CLOSE
CLOSE
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Full Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Online Application
First Name
*
Last Name
*
Applying For:
*
Applying For:
Myself
Loved One
D.O.B
*
Date Format: DD slash MM slash YYYY
Phone Number
*
Email Address
*
Insurance Name (if applicable)
Form Title
Page URL
CAPTCHA
×
Verify Your Insurance
Full Name
*
D.O.B
*
Date Format: DD slash MM slash YYYY
Phone
*
Email
*
Insurance Name
*
Member ID (optional)
Form Title
Page URL
CAPTCHA
×
×
