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General and Contact Information: Your Name: Day Phone #: Evening #:      Best Time to Call: Email : Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code: Your Relation to the Alcoholic/Addict: self son/daughter spouse parent friend employee other      If Other Please Specify: 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 ? less than 18 18 - 25 26 - 35 36 - 45 46 - 55 56 - 65 over 65 Current drug (s) their using:       A). Substance Abuse History: At what age did the individual start using the substance? Different drugs used:       Method of use:          Oral     IV-(inject)     inhale(smoke)     nasal(snort)     Other Past treatment attempts (What rehab, when, results:        B). Family History: Does anyone in the alcoholics/addicts immediate (blood) family have/or had a substance abuse problem?  yes  no Any losses (death) or departures (divorce-separations) from the family institution?       Ethnic/cultural background:    Asian-      American   Native-American       (Alaskan or Indian)   Euro-American       (Caucasian)   African-      American C). Social History Marital status: single married divorced widowed Any children?  yes  no who has parenting responsibilities? Has the individual enjoyed any social activities in the past? (if yes, specify)       Has there been a gradual shift to non-involvement in those activities? (if yes, when)       Has the individuals peer structure changed?  yes  no D). 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?       E). Educational History: Highest grade completed in grade school : 1 2 3 4 5 6 7 8 9 10 11 12 Some College College Graduate Vocational Tech?  yes  no Any desire or plan of continued or future education?       F). Occupational History Occupation: How Long? Is this the individuals chosen occupation?  yes  no      If no what is? Has the individual ever been terminated as a result of substance abuse?  yes  no G). 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:       H). Psychological and Behavioral History: Has the individual ever been diagnosed and treated for any psychological or emotional problems?  yes  no If yes, please specify what and when and outpatient or inpatient;        Was the individual prescribed medication for any psychological/emotional problem ?  yes  no       If yes, please list what drugs where prescribed and length of use:        On a Scale of 1-10, with 10 representing extreme urgency, and 1 representing information for later use. Please assign a number to this request : 1 2 3 4 5 6 7 8 9 10 Additional Information or Comments