If not, please enter the name of the person you are concerned about:

What is the addict's relationship to you?
husband wife father mother son daughter grandparent friend other

Drug History:

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

How were the drug(s) introduced into the body?

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

Did he/she receive medication for the disorder ?   yes   no

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

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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