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Free Pre-Intake Assessment Form


Welcome to the Cirque Lodge Pre-Intake Assessment form. This form is designed to collect the information necessary to help our staff structure an individualized alcohol or drug treatment program for our residents.

Please answer all the questions to the best of your ability as this will ensure you the finest help available as you begin your journey on the road to recovery. This assessment will include inquiries about; your insurance coverage, current physicians, family contacts, details about your personal history and desire for treatment, known disorders, history of addictions and drug abuses, history of personal traumas, prescribed medications, and other physiological conditions relevant to your overall mental and physical health.

The information you provide is kept strictly confidential. The form itself is secured with industry standard SSL Encryption for your protection.

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For more information please visit our Admission Guidelines