Is this inquiry for yourself ? yes no If not, please enter
the name of the person you are concerned about:
What is this addicts's relationship to you ?
Drug History:Please indicate
which drug(s) are involved in the problem:
| Drug of
How were the
drug(s) introduced into the body ?
What is the age of the addict ?
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?
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 ?
Does the person have any known medical conditions ? yes no
If yes, please describe
Has the person ever been diagnosed with a mental disorder ?
If yes, please specify:
Did he/she receive medication for the disorder ? yes no
Does the person have any alcohol/drug-related legal situations ?
yes, please describe them:
Does the addict express the desire to get off drugs/alcohol ?
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
Also add any other information that we
should know (best time to call, etc):