Assessments Start Your Rule 25 Assessment Here Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.LayoutName *Date of BirthStreet Address *LayoutCity *State *Zip *LayoutPhone NoAlternate PhoneEmail ID* *What is your reason for calling today?Do you have Health Care Insurance? Provider: (choose one)MEDICABC/BSPREF ONEHP UCAREMEDICA MHPHennepin HealthCCDTF/MALayoutPMI#Medical ID#Group#Who referred you to us?LayoutPO/Parole OfficerCourtsFamily/FriendLayoutAnother TX CenterOtherSelf ReferralLayoutIf treatment is recommended is there a provider you would prefer?Self ReferralWhat consequences have you had a result of your alcohol and/or drug use?LayoutHave you had a assessment or Rule 25 in the past 45 days?YesNoIs someone requiring you to receive a rule 25 assessment?YesNoLayoutWhat is your drug of choice?Date of Most Recent UseAmountSubmit
