Drug Treatment Questionaire

Please answer all the questions completely. This form will be used to help
our CCDCs (Certified Chemical Dependency Counselors) evaluate your situation
before recommending the appropriate treatment method for the addict's recovery.

Contact Information:

First Name:

M.I.

Last Name:

Address:

City:

State:

Zip Code:

Country:

Daytime Phone:

Evening Phone:

Please enter your email address

Is this inquiry for yourself?

Yes

No

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

First Name:

M.I.

Last Name:

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.):

YES

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Indicates Response Required