you wish to help?
If other, who are you concerned
old is the addict?
the addict want help?
list drugs abused:
does the addict obtain drugs/alcohol ?
describe any personal / family problems the addict has.
describe any legal problems the addict has.
describe the overall behavior & condition of the addict.
there any diagnosed medical condition? (Please describe)
there any diagnosed mental disorder? (Please describe)
the addict on any medication for any of the above?
the person ever attempted to stop using drugs before ?
If so, by which method?
the addict has received treatment, please describe? (Include
name of the facility, 12-step, etc.)
it a private program or a state-funded program ?
Was there any success with the prior treatment
? (How long did the addict stay clean, etc?)
there anything else you would like us to know?