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First Name:        

Last Name:        

City, State         

Phone:               

E-Mail:               

Is this regarding you?
 Yes
 No

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

What is the age of the addict?

Drug History:

Please indicate which drug(s) are involved
  Main Drug        Second Drug      Third Drug
          

How Used?
 Pills  Smoking  Intravenous  Snorting

Briefly describe this person's drug history

What problems has addiction caused the addict?

What problems has addiction caused their family?

What is the worst problem facing the addict?

Please describe briefly what is the current scene with the addict

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Crystal Meth Addiction - Abuse - Treatment - Drug Rehabs