Your Name*:
Email:
Day Phone #*: Evening Phone #*:
Address*:
City*:
State*: ---AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
Postal Code*:

Person you wish to help ?  Self Other
If other, who are you concerned about?
Addicts Name:
Relationship: ---HusbandWifeFatherMotherSonDaughterGrandparentFriendOther
How old is the addict ?  ---Less than 1818 - 2526 - 3536 - 4546 - 5556 - 65Over 65
Does the addict want help ?  Yes No
Please list drugs abused:
   Primary: ---AlcoholCocaineCrackHeroinMethamphetamineEctasyGHBInhalentsKetamineLSDMarijuanaMethadonePCPPrescription DrugsOther
   Second: ---AlcoholCocaineCrackHeroinMethamphetamineEctasyGHBInhalentsKetamineLSDMarijuanaMethadonePCPPrescription DrugsOther
   Third: ---AlcoholCocaineCrackHeroinMethamphetamineEctasyGHBInhalentsKetamineLSDMarijuanaMethadonePCPPrescription DrugsOther
How does the addict obtain drugs/alcohol ? 
     Works Steals Prescripton Deals Other
Can the addict travel?   Yes No
Please describe any personal / family problems the addict has.

Please describe any legal problems the addict has.

Please describe the overall behavior & condition of the addict.

Is there any diagnosed medical condition? (Please describe)

Is there any diagnosed mental disorder? (Please describe)

Is the addict on any medication for any of the above?   Yes No
   Medication? 
   How long? 
Has the person ever attempted to stop using drugs before ?  Yes No
If so, by which method?
 Self 12-Step Non-Hospital Residential Hospital  Other
If the addict has received treatment, please describe? (Include name of the facility, 12-step, etc.)

Was it a private program or a state-funded program ?   Private State-Funded 
Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)

Is there anything else you would like us to know?


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