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Phone # Home
Phone # Work
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Addict's First Name
Drug of Choice #1 Alcohol Addiction Cocaine Addiction Crack Addiction Codeine Addiction Crack Addiction Darvocet Addiction Demerol Addiction Dexedrine Addiction Dilaudid Addiction Ecstasy Addiction GHB Addiction Heroin Addiction Hydrocodone Addiction Lortab Addiction Marijuana Addiction Meth Addiction Methadone Addiction Morphine Addiction Opiate Addiction Opium Addiction OxyContin Addiction Percocet Addiction Percodan Addiction Ritalin Addiction Rohypnol Addiction Rohypnol Addiction Ultram Addiction Vicodin Addiction Other addiction
Drug of choice #2 Alcohol rehab Cocaine rehab Cocaine rehab Crack rehab Codeine rehab Darvocet rehab Demerol rehab Dexedrine rehab Dilaudid rehab Ecstasy rehab GHB rehab Heroin rehab Hydrocodone rehab Lortab rehab Marijuana rehab Meth rehab Methadone rehab Morphine rehab Opiate rehab Opium rehab OxyContin rehab Percocet rehab Percodan rehab Ritalin rehab Rohypnol rehab Ultram rehab Vicodin rehab Other drugs
Is Addict seeking help Yes No
List any Drug rehab program previously attended and if treatment was completed Detox completed Detox incomplete Drug rehab Outpatient incomplete Drug rehab Outpatient completed Drug rehab Long Term Incomplete Drug rehab Long Term completed Drug rehab residential incomplete Drug rehab Residential incomplete Drug rehab Twelve steps Drug rehab Religious Half Way House
Add any other information regarding Drug rehab program previously done.
Describe any medication history past or present(Name,Length, dosage etc.).
Describe addicted person's history (hospitalizations, psychiatric evaluations, present illnesses etc.)
Describe addicted person's legal history. (current & past charges or incarceration}
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