Petch Nava Hope CarePetch NavaPETCH NAVA HOPE CARE
Preliminary Assessment

Assessment for Families

For families seeking guidance on drug addiction treatment, filling out this assessment in advance helps our team prepare the most suitable approach before calling you to discuss the details — if you'd prefer to speak with us first without filling out the form, you can call us at 087-091-0385 or View other contact channels

All information in this assessment is kept confidential and used only for our team to prepare a preliminary plan of support. You do not need to answer every question — answer what you can and submit. Our team will contact you back to discuss further details.

1. Contact Information

For our team to contact you back

2. Patient Information

Optional — answer what you know

3. Family's Needs

Optional

4. Motivation for Treatment

Optional — select all that apply

5. Current Symptoms

Optional — select all that apply

6. Additional Information

Optional

Or call our team directly at 087-091-0385

Or call 098-653-5156 (Khun Pui)·086-366-2711 (Khun Num)

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