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You may also call 1-800-468-6933 from 8am to 11pm 7 days a week to speak with an admissions counselor.

Contact Information:

»Last Name: »First Name: »M.I.
»City: »State: »Zip Code:
»Daytime Phone:
»Evening Phone:
»Email :

»Is this inquiry for yourself ?  yes  no

If not, please enter the name of the person you are concerned about:
Last Name: First Name: M.I.

»What is this addicts's relationship to you ?

Drug History:

»Please indicate which drug(s) are involved in the problem:
Drug of Choice: Second Choice: Third 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 ?   

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

»Briefly describe the drug history of the addict.   

»What problems has addiction caused the addict?

»What problems has 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 this 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, please specify:

»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 higest 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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