Drug Addiction
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Last Name:
First Name:


Zip Code:
Phone #:

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 the addict's relationship to you?

Drug History:

Please indicate which drugs(s) are involved in the problem:

1st Choice
2nd Choice
3rd 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?

Briefly describe the drug history of the addict.

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

What problems has the addiction caused the addict?

What problems has the 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 the 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, what?

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 highest 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.)

Would you like to receive more information on addiction?
yes no



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