First Name:       

Last Name:       

City, State       

Phone:              

E-Mail:              

If not, how are you connected/related to this person

What is the age of the addict?
... less than 18 18-25 26-35 36-45 46-55 56-65 over 65

Drug History:

Please indicate which drug(s) are involved
Main Drug         Second Drug       Third Drug
... Cocaine Alcohol Crack Heroin Meth Other        ... Cocaine Alcohol Crack Heroin Meth          ... Cocaine Alcohol Crack Heroin Meth

How Used?
Pills  Smoking  Intravenous  Snorting

Briefly describe this person's drug history


What problems has addiction caused the addict?

What problems has addiction caused their family?

What is the worst problem facing the addict?

Please describe briefly what is the current scene with the addict

Security Code: