Contact Information:

First Name: 

Last name:   

Address: 

City:   

State:     Zip:

Day Phone Number:

Evening Phone Number

When is the best time to call?
(Note: For privacy reasons, we do not leave messages unless you say it is okay to.)

Email Address

Is this inquiry for yourself?    Yes     No

If not, for whom?

First Name:

Last Name:

What is their relationship to you?    None Spouse Parent Son/Daughter Brother/Sister Other Relative Friend Other

Drug History

Please indicate which drugs are involved in the problem

Drug of Choice: Alcohol Cocaine Crack Heroin Meth Ecstasy GHB Inhalants Ketamine LSD Marijuana Methadone PCP Prescription Other     Second Choice: None Alcohol Cocaine Crack Heroin Meth Ecstasy GHB Inhalants Ketamine LSD Marijuana Methadone PCP Prescription Other

Third Choice: None Alcohol Cocaine Crack Heroin Meth Ecstasy GHB Inhalants Ketamine LSD Marijuana Methadone PCP Prescription Other

How were the drugs introduced into the body?

Intravenous        Smoking            Snorting                Pills

What is the age of the addict?

Briefly describe the history of the addict:

What problems has the addiction caused the addict?

What problems has the addiction caused the family?

What kind of help do you think the addict needs?

What is the worst problem the addiction has caused the addict?

How would the Inpatient Care be financed (insurance - what type; cash, work-study - if available)?

Other Information:

Please describe briefly what is going on with this person right now.
Please add any other info you think we should know (i.e. best time to call)