If not, please enter the name of the person you are concerned about:

What is the individual's relationship to you?
husband wife father mother son daughter grandparent friend other

Drug History:

Please indicate which drugs(s) are involved in the problem:

How were the drug(s) introduced into the body?

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 the treatment have?

Medical History:

Has the person ever been diagnosed with a mental disorder?

yes no

If the person has been diagnosed for a mental disorder, is the person on medication  yes  no

Legal History:

Does the person have any alcohol/drug-related legal situations?
yes no

If yes, please describe them:

Other Information:

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.)