Myself Family Member Friend Coworker Other

First Name: 

Last Name:  

Age:  

E-mail: 

Phone Number:  

Having any problems with work or school?

  Yes

  No

  Maybe

Having any family or social problems?

  Yes

  No

  Maybe

Having any financial difficulties?

  Yes

  No

  Maybe

Having any legal problems?

  Yes

  No

  Maybe

Had any prior treatment?

  Yes

  No

What is your drug of choice? 

What other drugs / substances have you used or experimented with?

Do you have any medical conditions?  If so, please list:

Do you use prescription medications of any kind? If so, please list name, strength, and frequency of use:

Have you ever attended 12-step meetings?

  Yes

  No

What is your longest period of sobriety to date? How long ago was this?

Do you have any questions for us?