Facility Name ___________________________________________________

Please check (ONLY ONE) which Program Type best describes your facility.

[ ] Freestanding Chemical Dependency Rehab

[ ] Psychiatric Hospital with Chemical Dependency Patients Housed Separately

[ ] Psychiatric Hospital with Integrated Chemical Dependency Treatment

[ ] General Hospital with Separate Chemical Dependency Rehab Unit

[ ] Long Term Residential Program (12 Step Orientation emphasized and structured professionally managed programming)

[ ] Therapeutic Community (Up to 2 year residential treatment in TC tradition)

Number of Beds ________________

Detox Available YES NO

Last Year's Admissions:

Total Number: Adolescents _______________ Adults ________________

Average Length of Stay ________________

Percent of Women ________________

Percent under 25 ________________

Percent with College Education (estimate) ________________

Percent covered by Public Assistance ________________

Percent receiving some form of psychiatric
medication other than for detoxification ________________

Admissions Procedures:

Night Admission Available	YES	NO
Weekend Admission Available	YES	NO
Face to Face Interview or exam required before admission	YES	NO

Self Statements: Please describe the following in ONE SENTENCE.

1. Facility's inpatient program.

2. Program's treatment philosophy.

3. Program's approach on dual diagnosis.

4. Program's family program.

5. Program's position on 12 Step involvement.

6. Program's position on confrontation.

7. List any additional characteristics that distinguish your program

Special Populations

Using the following numbered responses, please indicate by circling the appropriate number(CIRCLE ONLY ONE), which statement best describes your facility's programs with the following special populations. Please don't circle anything, if your facility does not address this population.

1. Facility has separate program in which programming is exclusively for this special population.

2. Facility has special track with at least 1/3 of programming exclusively devoted to this special population.

3. Facility has group sessions exclusively for this special population.

Example: Adolescent (1) 2 3 [#1 is circled indicating facility has separate program for adolescents.]

	Separate Program	Special Track	Group Sessions
Abuse/PTSD/Trauma	1	2	3
Acute Care	1	2	3
Adolescents (12-18)	1	2	3
Alcohol Addiction	1	2	3
Anger Management/Conflict Resolution	1	2	3
Anorexia/Bulimia	1	2	3
Attorneys & Judges	1	2	3
Blind	1	2	3
Clergy	1	2	3
Cocaine Addiction	1	2	3
Codependency	1	2	3
Compulsive Gambling	1	2	3
Compulsive Overeating	1	2	3
Criminal Justice	1	2	3
Crystal Meth	1	2	3
Deaf	1	2	3
Depression	1	2	3
Domestic Violence	1	2	3
Family	1	2	3
Gay & Lesbian	1	2	3
Geriatric	1	2	3
Grief & Loss	1	2	3
Healthcare Professionals	1	2	3
Heroin Addiction	1	2	3
HIV/AIDS	1	2	3
Inhalant Abuse	1	2	3
Internet Addiction	1	2	3
Marijuana	1	2	3
Men	1	2	3
Mentally Retarded & Developmentally Disabled	1	2	3
Methadone	1	2	3
Native American	1	2	3
Nicotine Cessation	1	2	3
Obsessive Compulsive	1	2	3
Pain Management	1	2	3
Parenting/Life Skills	1	2	3
Physically Challenged	1	2	3
Pregnant Women	1	2	3
Prescription Drugs	1	2	3
Professional Renewal/Training	1	2	3
Psychiatric (Dual Diagnosis)	1	2	3
Relapse	1	2	3
Sexual Addictions	1	2	3
Spanish Speaking	1	2	3
Uniformed Services	1	2	3
Vocational Skills	1	2	3
Wilderness Program	1	2	3
Women	1	2	3
Workaholism	1	2	3
Young Adults (18-25)	1	2	3
Other Specialized Programs
_________________________________	1	2	3
_________________________________	1	2	3
_________________________________	1	2	3
_________________________________	1	2	3

Payment Information

Self-pay Cost per Week
Public Assistance coverage may be accepted	YES	NO
Medicare Coverage accepted	YES	NO
Insurance Coverage verified before admission	YES	NO
Follow-up Care included at not additional charge	YES	NO

Licensing and Accreditation (MUST COMPLETE)

Licensed by: ______________________________________

Type of License ___________________________________

Accredited by _____________________________________

Contact Information

Admissions Telephone Number: _____________________

General Telephone Number: ________________________

Address __________________________________________

__________________________________________

Contact Person for future update and WEB related Business

Name: ___________________________________

Title: __________________________________

E-mail address: _________________________

Fax Number: _____________________________

Do you have a website, and if so what is the URL: ______________________

FAX COMPLETED QUESTIONNAIRE TO:

Ms. Polly Waldman, Addiction Resource Guide, Fax #: 914.631.8077

or mail it to same at:

Addiction Resource Guide, P.O. Box 8612, Tarrytown, New York 10591