Momentum – Substance Abuse and Mental Health Resource

Which of these are causing problems?

Many people use more than one. Knowing which ones helps us find the right treatment.

Type Substances here or choose from above..

How hard is it to stop using?

You do not need to do this alone. The right treatment can make it easier.

How hard is it to stop using?

Able to stop for a week or longer Can stop but might use again within a week Have trouble stopping at all Not sure

What withdrawal symptoms would occur if substance use stopped?

It’s normal to worry about withdrawal. There are things that can help.

What withdrawal symptoms would occur if substance use stopped?

No symptoms Mild headache, shakes, nervousness, & trouble sleeping Trouble with nerves, shakes, stomach, & getting to sleep Too nervous to think, bad shakes, can't hold down food or water, can't sleep Could have seizures, serious heart problems, high blood pressure, or see or feel things that aren't there.

Any physical health needs?

People are balancing more than just addiction. We can help you find treatment that considers all medical needs.

Any physical health needs?

Need to see a doctor for chronic conditions (diabetes, high blood pressure, etc.) May need help during day/night for serious medical conditions (cancer, etc.) May need urgent care now (seizures, vomiting blood, etc.)

Any problems with mental health?

Addiction and mental health can go hand in hand. With the right support, people can feel better.

Any problems with mental health?

None Bothered but able to take care of things Some difficulty taking care of things Trouble working, managing things at home, or dealing with others Can’t really handle life or be safe Prefer not to answer

Any suicidal thoughts or thoughts of self-harm?

Life can be hard and you deserve support. We can help you find it. For urgent needs, call 988.

Any suicidal thoughts or thoughts of self-harm?

No Yes, suicidal thoughts, would not hurt self Yes, suicidal urges, may not be safe Prefer not to answer

Need help with any of these?

Everyone has different needs. We can find places that help with these things.

Need help with any of these?

Getting to and from treatment Walking or getting around in general A routine to avoid drugs or alcohol None of these

Any other help needed?

Select all that apply

We all need help sometimes. We can find services to take care of things that get in the way of treatment.

Is there a legal requirement for residential treatment?

Here to assist. If there is a legal reason for a specific type of treatment we can help you find the right place.

Is there a legal requirement for residential treatment?

No Yes Prefer not to answer

Ready to start treatment?

We're here to help you on this journey.

Ready to start treatment?

Interested in whatever treatment is recommended Will consider some things but not others Not sure Not interested in treatment now

One last step.

Please provide us this information so we can contact you directly and address your needs.

Name*

Phone Number*

Email*

Give yourself the gift of a better and healthier you

Thank you.

Do you need support now?

Book A Consultation

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