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Person you wish to help ?
self
other
If other, who are you concerned about:
How old is the addict ?
Does the addict want help ?
yes
no
Please list drugs abused:
| Primary: |
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| Second: |
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| Third:
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How does the addict obtain drugs/alcohol ?
Please describe any personal / family problems the addict has.
Please describe any legal problems the addict has.
Please describe the overall behavior & condition of the
addict.
Is there any diagnosed medical condition? (Please describe)
Is there any diagnosed mental disorder? (Please describe)
Was the addict on any medication for any of the above?
yes
no
Has the person ever attempted to stop using drugs before ?
yes
no
If so, by which method?
If the addict has received treatment, please describe? (Include name of the facility, 12-step, etc.)
Was it a private program or a state-funded program ?
private
state-funded
Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)
Is there anything else you would like us to know?
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