Addiction Resource Guide

Outpatient Directory Information Questionnaire & Order Form
Directions: Print out the following questionnaire and order form. Fill them out completely and accurately, to obtain an Outpatient Directory listing. Pricing information is included on the order form. If you have questions, please email, Polly Waldman at pbw@addictionresourceguide.com. Mail the completed form, along with a check payable to Addiction Resource Guide, to Addiction Resource Guide, P.O. Box 8612, Tarrytown, NY 10591, Attn: Polly Waldman.

Facility Name ___________________________________________________

Facility Address: Street: ______________________________________

City: _________________________County: ____________State: ________Zip _________

General Phone: ______________Admissions Phone: ____________Fax: ____________

24 Hour HOTLINE: [ ] If so, number: ____________________________________

Outpatient Detox Available: [ ]

(check one only) Hospital Based: [ ] or Freestanding: [ ]



LICENSING AND ACCREDITATION

Licensed by: __________________________________________________________

Type of License: ______________________________________________________

Accredited by: ________________________________________________________



CHARACTERISTICS OF YOUR FACILITY'S CD CLIENT POPULATION


Average number of individuals seen each week ______________

Average number of adolescents seen each week _____________

Percent receiving treatment 3 times a week or more __________________

Percent employed _______________

Percent women _______________

Percent of CD clients primarily alcohol dependent _________________

Percent of CD clients primarily drug dependent _________________

Percent active in 12 Step group AND have a sponsor ________________

Percent receiving individual sessions only _________________

Percent receiving psychiatric medication (from any source) _________________



DESCRIBE YOUR FACILITY'S OUTPATIENT PROGRAM


What makes you different and special?





Who do you serve?





What is your treatment philosophy?





Describe family component of program?





Is evening treatment available?






CONTACT PERSON FOR FUTURE UPDATE AND WEB RELATED BUSINESS

Name _______________________________________Title ______________________

Telephone # ________________________________Fax ________________________

Email Address ______________________________URL ________________________



Outpatient Directory Order Form
Directions: Check ONE of the following options for a Directory Listing in Addiction Resource Guide's Outpatient Treatment Facility Directory.


Facility Name: _________________________________________________________

Slogan to be used in directory under facility name (50 characters, including spaces)

________________________________________________________________

________________________________________________________________



MAIL COMPLETED QUESTIONNAIRE AND ORDER FORM WITH CHECK TO:



© Addiction Resource Guide 2011


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