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Information:
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Fill out the
below form providing as much data as you can so we can help you best.
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| First
name:
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| Last
name:
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| Address:
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| City
and
zip
code:
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| Country: |
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| Phone
number: |
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| E-mail
address: |
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| Is
this
inquiry
for
yourself:
Yes No |
| If
not,
please
enter
the
name
of
the
person you are concerned about: |
| First
name: Last name: |
| What
is
this
addict's
relationship
to
you?
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Please
indicate
which
drug(s)
are
involved
in
the
problem:
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| How
were
the
drug(s)
introduced
into
the
body? |
Intravenous
Smoking Snorting Pills |
| What
is
the
age
of
the
addict? |
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When
did
the
addict
start
using drugs? |
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| At
what
age
did
the
addict
exhibit
behavior
changes?
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| What
were
the
changes? |
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Are
there
any
major
events
contributing
to
this
problem
?
(For example: trauma, death, abuse, etc.). |
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| Briefly
describe
the
drug
history
of
the
addict: |
| What
problems
has
addiction
caused
the
addict:
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| What
problems
has
addiction
caused
the
family:
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| Treatment
History: |
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| Has
the
person
ever
undergone
addiction
treatment?
Yes No |
| If
so,
when
and
where?
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| Was
it
a
private
program
or
a
state-funded
program?
Privat State |
Was
it
a
traditional
12-step
program
or
another
type?
12
steps
Another
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| What
effect
did
this
treatment
have?
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| Medical
History:
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| Does
the
person
have
any
known
medical
conditions?
Yes
No |
| If
yes,
please
describe
them:
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| Has
the
person
ever
been
diagnosed
with
a
mental
disorder?
Yes No |
| If
yes,
please
specify: |
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| Did
he/she
receive
medication
for
the
disorder?
Yes
No |
| If
yes,
what
and
how
long
was
it
taken? |
| Other
Information: |
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| Does
the
addict
express
the
desire
to
get
off
drugs/alcohol Yes No |
| What
is
the
higest
level
of
education
completed
by
the addict ?
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| Is
there
anything
that
would
prevent
the
addict
from
receiving help? |
| Please
Describe:
|
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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Drug
and Alcohol Prevention and
Rehabilitation