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Is this inquiry for yourself? yes no
If not, please enter the name of
the person you are concerned about:
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 ?
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 kmow (best time to call, etc):
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