| A).
Medical History:
 Does
the individual have any medical
problems? (Please describe)
Is the individual currently taking
any medications?
yes
no
If
yes, please specify what and length of
use:
B).
Legal History:
Does
the individual have a valid drivers
license? yes
no
Has
the individual ever been arrested? (If
so, for what)
Are
any crimes actively being committed to
support, or as a result of the
alcoholism or addiction?
C).
Substance Abuse History:
At
what age did the individual start using
the substance?:
Different
drugs used:
Method
of use:
 Past
treatment attempts (What rehab, when,
results:
D).
General Contact Information:
Your
Relation to the Alcoholic/Addict:
Alcoholics/Addicts
Name:
City
and State in which they live:
Can
they travel outside of this area for
treatment? yes
no
How
old is the addict ?
Current
drug (s) their using:
|