|
Person you wish to help?
self
other
If other,
who are you concerned about:
How old is the addict?
Does the addict want help?
yesno
Please list
drugs abused:
| Primary: |
|
| Second: |
|
| Third: |
|
How does the addict obtain drugs/alcohol ?
Please describe any personal / family problems the addict
has.
Please describe any legal problems the addict
has.
Please describe the overall behavior & condition of the
addict.
Is there any diagnosed medical condition? (Please
describe)
Is there any diagnosed mental disorder? (Please
describe)
Did the addict on any medication for any of the
above?
yes no
Has the person ever attempted to stop using drugs before
?
yes no If so, by which method?
If the addict has received treatment, please describe? (Include name
of the facility, 12-step, etc.)
Was it a private program or a state-funded program
?
private state-funded
Was there any success with the prior treatment ? (How long did the
addict stay clean, etc?)
Is there anything else you would like us to
know?
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