|
 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
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 know (best time to call, etc):
| 
