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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 addict?
Drug History: Please indicate which drug(s) are involved Main Drug Second Drug Third Drug
How Used?
Briefly describe this person's drug history
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
Crystal Meth Addiction - Abuse - Treatment - Drug Rehabs