Skip to content

About
Programs
Donate
- Make a Donation
- Reyn’s Fund
News
- Events
- Chrysalis Luncheon
FAQ
- Resources
- Sliding Fee Program
Careers
Contact

Menu

About
Programs
Donate
- Make a Donation
- Reyn’s Fund
News
- Events
- Chrysalis Luncheon
FAQ
- Resources
- Sliding Fee Program
Careers
Contact

Haven-Logomark-White

seeking help

If you are seeking treatment for a substance use disorder, completing the following questions will help the staff at The Haven ensure that you have access to appropriate treatment. A staff member will contact you within 72 hours.

Questionnaire for prospective clients

Name(Required)

First Last

Date of birth(Required)

MM slash DD slash YYYY

Phone(Required)

Email(Required)

List the substances you are using to get drunk or high(Required)

How many times per day or week?(Required)

Injecting?(Required)

Yes

No

List the substances you are using to get drunk or high

How many times per day or week?

Injecting?

Yes

No

List the substances you are using to get drunk or high

How many times per day or week?

Injecting?

Yes

No

List the substances you are using to get drunk or high

How many times per day or week?

Injecting?

Yes

No

When was the last time you used?(Required)

Please list any treatment programs you have participated in(Required)

If you have children, please list them by age and include if you or someone else is caring for them(Required)

Is the Department of Child Safety involved in the care of your children?(Required)

Yes

No

Are you currently pregnant?(Required)

Yes

No

Unsure

Have you been diagnosed with any mental illnesses?(Required)

Yes

No

If yes, list any agencies you are receiving mental health services from(Required)

Do you currently have any medical conditions? If so, please list.(Required)

List any prescription medications you are taking(Required)

Do you currenlty have any legal cases/charges?(Required)

Yes

No

Please list any probation, parole, or court programs you are participating in(Required)

What is your current living situation?(Required)

Are you worried about becoming homeless?(Required)

Yes

No

Please list any health/medical insurance plans or benefits(Required)

Email

This field is for validation purposes and should be left unchanged.

Residential

1107 E. Adelaide Dr. Tucson, AZ 85719
520.623.4590

Outpatient

2601 N. Campbell Ave. Suite 105
Tucson, AZ 85719
520.623.4590

Tax information

Tax ID #23-7112026
Arizona Tax Credit QCO Code 20590

Pages

About Us
Programs
Donate & Volunteer
Reviews
Resources
Contact us
Referrals and Funding

Privacy Policy
Website Accessibility Policy
Non-Discrimination Policy
Board Log In

Sign Up for Newsletter

Name

Email

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

© 2024 The Haven. All rights reserved.

Tucson Web Design by Anchor Wave.

Facebook Instagram

Skip to content

Accessibility Tools

Increase Text
Decrease Text
Grayscale
High Contrast
Negative Contrast
Light Background
Links Underline
Readable Font
Reset