heroinaddiction.com

Last Name:

First Name:

M.I.

Address:

City:

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Daytime Phone:

Evening Phone:

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Is this inquiry for yourself?

Yes

No

If not yourself, what is the addict's name and relationship to you?

Last Name:

First Name:

M.I.

What is the 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?

Intravenous

Smoking

Snorting

Pills

What is the age of the addict?

Briefly describe the drug history of the addict:

What problems has addiction caused the addict?

What problems has the addiction caused the family?

What kind of help do you think the addict needs?

What is the worst problem addiction is causing the addict?

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.):

* Would you like to recieve more information on addiction?

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