Your First Name:
Your Last Name:
Email :
Day Phone #:
Night Phone #:
Address:
City:
State:
Postal Code:

Person you wish to help ?  self  other

If other, who are you concerned about:
Name:
Relationship:
How old is the addict ?


Does the addict want help ?
 yes  no

Please list drugs abused:
Primary:
Second:
Third:

Please describe any personal / family problems the addict has.

Please describe any legal problems the addict has.

Please describe generally how the addict behaves at present.

Does the addict suffer from any present medical conditions? (Please describe)

Has the addict been diagnosed with a mental disorder? (Please describe)

Has the addict ever been prescribed Psyciatric drugs? (prozac, wellbutrin, rittalin,etc) yes  no

Medication?
How long ?
Medication?
How long ?
Medication?
How long ?
Is the addict presently on any other prescription medication yes  no If so please descibe.


Has the addict been to prior drug and alcohol treatment?
 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.)

Treatment 1


Treatment 2


Treatment 3

How was the program funded?  private  state-funded

Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)

General information about the addict or family?