First Name:       

Last Name:       

City, State       

Phone:              

E-Mail:              

If not, how are you connected/related to this person

What is the age of the Self Medicater or Addict?
... less than 18 18-25 26-35 36-45 46-55 56-65 over 65

Drug History:

Please indicate which drug(s) are involved
Main Drug                      Second Drug                     Third Drug
... Alcohol Prescription Drugs Over the Counter Cocaine Crack Heroin Meth Other      ... Alcohol Over the Counter Cocaine Crack Heroin Meth          ... Alcohol Prescription Drugs Over the Counter Cocaine Crack Heroin Meth

How Used?
Pills  Smoking  Intravenous  Snorting

Briefly describe this person's drug history


What problems has using medications caused the addict?

What problems has using medications caused their family?

What is the worst problem facing the self medicater?

Please describe briefly what is the current scene with this person.

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