First Name:
Last Name:
Contact Me:
Phone Number:
Alternate Phone:
State:
Outside US Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennesse Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Email Address:
How Did You Hear of Us:
If By Another Agency Which:
You are contacting us for:
If other than self enter name:
Time Zone:
Pacific Mountain Central Eastern
Drug of Choice:
Method of Intake:
Secondary Drug of Choice:
Method of Taking:
Age of First Use:
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Over 60
Age Now:
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Over 60
Age of Unmanageability:
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Over 60
Current Problems of Addiction:
Family Attitude:
Does User admit to Problem:
Does User want Help:
Times of Prior Treatment:
O 1 2 3 4 5 6 7 8 9 10 Over 10
How Many were 12 Step:
All Some None NA
Any Success:
Any Known Medical Condition:
If Yes Please List:
Any Psychiatric Disorder:
Please List:
Taking Psychiatric Medication:
Please List Medications:
Any Legal Problems:
Please Describe:
Have any Questions for Us:
www.addiction-enders.com www.drugfreereferral.com www.newlifecentersf.org