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on-line consultation

You may also call 1-800-468-6933 from 8am to 11pm 7 days a week to speak with an admissions counselor.

Contact Information:

Last Name: First Name: M.I.
City: State: Zip Code:
Phone #:
Email :

Is this inquiry for yourself ?  yes  no

      If not, please enter the name of the person you are concerned about:
     Last Name: First Name: M.I.

What is this addicts's relationship to you ?

Drug History:

Please indicate which drug(s) are involved in the problem:
     Drug of
Second Choice:  Third Choice: 

How were the drug(s) introduced into the body ?  
       Intravenous     Smoking     Snorting     Pills

What is the age of the addict ?

When did the addict start using drugs ?   

At what age did the addict exhibit behavior changes ?   

What were the changes ?   

Are there any major events contributing to this problem ?
     (For example: trauma, death, abuse, etc.)

Briefly describe the drug history of the addict.   

What problems has addiction caused the addict?

What problems has addiction caused the family? 

Treatment History:

Has the person ever undergone addiction treatment ?  yes  no

     If so, when and where ?   

Was it a private program or a state-funded program ?  private  state-funded

Was it a traditional 12-step program or another type ?  12-step  other

What effect did this treatment have ?   

Medical History:

Does the person have any known medical conditions ?  yes  no

     If yes, please describe them:   

Has the person ever been diagnosed with a mental disorder ?  yes  no

     If yes, please specify:

Did he/she receive medication for the disorder ?  yes  no

     If yes, what ?

How long was it taken ?

Legal History:

Does the person have any alcohol/drug-related legal situations ?  yes  no

     If yes, please describe them:   

Other Information:

Does the addict express the desire to get off drugs/alcohol ?  yes  no

What is the higest level of education completed by the addict ?

Is there anything that would prevent the addict from receiving help ?  

Please describe briefly what is going on with this person right now.
     Also add any other information that we should know (best time to call, etc):



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