Self-Assessment - Gallus Detox Centers

Step 1 of 11

What is your date of birth?(Required)

Month

Day

Year

What is your gender?

Male

Female

Non-Binary

Are you over 12 weeks pregnant?(Required)

Yes

Have you had detox treatment before?(Required)

Yes

If you have had detox before, did you experience:

Withdrawal seizures

Yes

Delirium Tremens

Yes

Admitted to ER/Hospital in the last 3 months

Yes

Please indicate which Gallus location you are interested in going to(Required)

How would you like to pay for treatment:(Required)

Commercial Health Insurance

Pay directly

Tricare/Medicare/Medicaid

Note: Gallus is unable to accept this payment option at this time

What is your zip code? (must be a valid zip code in the U.S.)(Required)

ZIP Code

Please provide your first name(Required)

Please indicate the substances you are using:

Alcohol

Heroin

Fentanyl

Methadone

Suboxone Buprenorphine/Naloxone

Clonazolam

Kratom

Marijuana

Benzodiazepines

Xanax

Klonopin

Ativan

Valium

Tranxene

Short-Acting Opioids

Oxycodone

Percocet

Hydrocodone

Norco/Vicodin/Lortab

Morphine IR

Hydromorphone

Dilaudid IR

M30

Long-Acting Opioids

Oxycodone ER

Oxycontin

Oxymorphone

Opana

Morphine ER

MS Contin

Stimulants

Ritalin

Dexedrine

Adderall

Vyvanase

Atomoxetine

Provigil

Cocaine

Methamphetamine

Alcohol

Strength/Amount

Intoxicated

Frequency

1-2x week

3x a week

Duration

Less than 6 weeks

Greater than 6 weeks

Xanax

Strength/Amount

Less than 6mg

Greater than 7mg

Frequency

daily

weekly

Duration

Less than 1 mo

Greater than 1 mo

Klonopin

Strength/Amount

Less than 6mg

Greater than 7mg

Frequency

daily

weekly

Duration

Less than 1 mo

Greater than 1 mo

Ativan

Strength/Amount

Less than 15mg

Greater than 15mg

Frequency

daily

weekly

Duration

Less than 1 mo

Greater than 1 mo

Valium

Strength/Amount

Less than 100mg

Greater than 100mg

Frequency

daily

weekly

Duration

Less than 1 mo

Greater than 1 mo

Tranxene

Strength/Amount

Less than 100mg

Greater than 100mg

Frequency

daily

weekly

Duration

Less than 1 mo

Greater than 1 mo

Oxycodone

Strength/Amount

Less than 200mg

Greater than 200mg

Frequency

daily

weekly

Duration

Less than 2 mos

Greater than 2 mos

Percocet

Strength/Amount

Less than 200mg

Greater than 200mg

Frequency

daily

weekly

Duration

Less than 2 mos

Greater than 2 mos

Hydrocodone

Strength/Amount

Less than 200mg

Greater than 200mg

Frequency

daily

weekly

Duration

Less than 2 mos

Greater than 2 mos

Norco/Vicodin/Lortab

Strength/Amount

Less than 200mg

Greater than 200mg

Frequency

daily

weekly

Duration

Less than 2 mos

Greater than 2 mos

Morphine IR

Strength/Amount

Less than 200mg

Greater than 200mg

Frequency

daily

weekly

Duration

Less than 2 mos

Greater than 2 mos

Hydromorphone

Strength/Amount

Less than 200mg

Greater than 200mg

Frequency

daily

weekly

Duration

Less than 2 mos

Greater than 2 mos

Dilaudid IR

Strength/Amount

Less than 200mg

Greater than 200mg

Frequency

daily

weekly

Duration

Less than 2 mos

Greater than 2 mos

M30

Strength/Amount

Less than 200mg

Greater than 200mg

Frequency

daily

weekly

Duration

Less than 2 mos

Greater than 2 mos

Oxycodone ER

Strength/Amount

Less than 10mg

Greater than 10mg

Frequency

daily

weekly

Duration

Less than 1 mo

Greater than 1 mo

Oxycontin

Strength/Amount

Less than 10mg

Greater than 10mg

Frequency

daily

weekly

Duration

Less than 1 mo

Greater than 1 mo

Oxymorphone

Strength/Amount

Less than 10mg

Greater than 10mg

Frequency

daily

weekly

Duration

Less than 1 mo

Greater than 1 mo

Opana

Strength/Amount

Less than 10mg

Greater than 10mg

Duration

Less than 1 mo

Greater than 1 mo

Frequency

daily

weekly

Morphine ER

Strength/Amount

Less than 10mg

Greater than 10mg

Frequency

daily

weekly

Duration

Less than 1 mo

Greater than 1 mo

MS Contin

Strength/Amount

Less than 10mg

Greater than 10mg

Frequency

daily

weekly

Duration

Less than 1 mo

Greater than 1 mo

Heroin

Strength/Amount

Less than 2g

Greater than 2g

Frequency

1x week

Greater than 4x week

Duration

Less than 1 week

Greater than 1 week

Fentanyl

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 1 week

Greater than 1 week

Methadone

Strength/Amount

Less than 40mg

Greater than 40mg

Frequency

daily

weekly

Duration

Less than 1 week

Greater than 1 week

Suboxone Buprenorphine/Naloxone

Strength/Amount

Less than 8mg

9-16mg

Greater than 16mg

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Ritalin

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Dexedrine

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Adderall

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Vyvanase

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Atomoxetine

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Provigil

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Cocaine

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Methamphetamine

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Clonazolam

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Kratom

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 2 weeks

Greater than 2 weeks

Marijuana

Strength/Amount

Any

Frequency

1x week

Greater than 4x week

Duration

Less than 1 mo

Greater than 1 mo

Please provide your email or phone and a Gallus representative will reach out to you.

Phone

Great news! Your answers indicate that we can help you recover at Gallus Medical Detox Centers

Please choose the best way for our admissions team to connect with you(Required)

Call me

Text me

Email me

Confidential Self Assessment Form

Complete the following questions to confirm if you are eligible for medical detox.

If you have had detox before, did you experience:

Note: Gallus is unable to accept this payment option at this time

Alcohol

Xanax

Klonopin

Ativan

Valium

Tranxene

Oxycodone

Percocet

Hydrocodone

Norco/Vicodin/Lortab

Morphine IR

Hydromorphone

Dilaudid IR

M30

Oxycodone ER

Oxycontin

Oxymorphone

Opana

Morphine ER

MS Contin

Heroin

Fentanyl

Methadone

Suboxone Buprenorphine/Naloxone

Ritalin

Dexedrine

Adderall

Vyvanase

Atomoxetine

Provigil

Cocaine

Methamphetamine

Clonazolam

Kratom

Marijuana

Please provide your email or phone and a Gallus representative will reach out to you.

Great news! Your answers indicate that we can help you recover at Gallus Medical Detox Centers

Or contact our admissions team directly by calling (888) 306-3122

Ready to get help now?