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First name *
Last Name
City, State
Phone *
E-mail Address: *
Is this regarding you? *yes
If not, how are you connected/related to this person?
What is the age of the addict? *
Main Drug being used *
Second Drug being used
Third Drug being used
Briefly describe this persons drug history *
What problems has alcohol caused the addict?
What problems has alcohol caused the family?
What is the worst problem facing the alcoholic?
Please describe briefly what the current scene is with the addict *

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