Who We Are
What We Do
HR / Employment
Date Of Birth
Substance Abuse History (please include alcohol. prescription drugs, and street drugs)
What is the primary drug of abuse?
THC (pot, Hash)
Amphetamines (Crystal, Ice, Mini Thins, Ritalin, Adderall)
Opiates (Heroin, Morphine, Oxycontin, Loritab, etc)
Benzodiazepines (Valium, Rohyponal Xanax, Xanbar)
Inhalants (Gas, Freon, Rush, Aerosols, Nitrate)
Hallucinogens (LSD (acid), Peyote Mescaline, Mushrooms)
Club Drugs (Ecstasy, GHB, Angel Dust, Ketamine
Method of use?
How long have you been using your drug of choice?
What are some ways that your drug use has affected your life?
Would you like to do an initial phone assessment?
Drug Use History
Do your friends and family see you as a different person when you are under the influence?
if so, please explain.
Have you experienced any negative consequences as a result of being under the influence?
If so, please describe:
Please provide us with any other information and any questions you may have:
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