844-LifeChange (543-3242)
GET HELP. CALL OUR ADDICTION HELPLINE 844-LifeChange (543-3242)

Online Clinical Assessment Form

2 Methods To Get Us Info We Need In Order to Best Help You
For Lighthouse Network to find the best treatment option(s) customized to your specific clinical and financial situation, we need to get some information about you. Some people prefer to call and speak to someone directly while for others, a better fit is to fill out an online form. Because we know time, energy, stress, and other demands are going on in your life, we have 2 ways of getting us your information.

  1. Call our Helpline, 844-Life-Change (844-543-3242) and speak to one of our Care Guides to open you case.
    Fill out our online Clinical Assessment Form that will be submitted to our Care Guides.
  2. This form is not designed to be diagnostic or comprehensive. I designed this tool to provide the essential information to best determine the right fit for your clinical situation and financial situation.

Doctors, Therapists, and Pastors
Always feel free to call our Helpline to access our Case Management and Placement services. But if it more convenient for you to fill out this form instead, certainly feel free to provide the appropriate information for us to help the person you are caring for get the best treatment.

If You Or Someone You Love Is Struggling
Individuals, or a loved one looking for options for someone who is struggling, can also fill our this form. It is not very technical and is mostly menu driven. Just check the boxes. When the form asks for the clinicians name and info, just put yours.

You can also use this as a screening tool or assessment form to take an honest look at how significant your struggles are. For more screening tools, please click here.

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  • Basic Demographics

  • Please enter a value between 1 and 99.

Lighthouse Network is Here to Serve You
This Assessment Tool is designed to be another way for us to serve you. If you have trouble with the form or it is easier to talk to one of our Care Guides, we are always happy to serve you on the phone. Don’t hesitate or think it is an imposition. We are blessed when we help you.