Person you wish to help ?   self   other

How old is the addict ? less than 18 18 - 25 26 - 35 36 - 45 46 - 55 56 - 65 over 65

Does the addict want help ?   yes   no

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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