Contact information  Your Name, First & Last  Your Phone Number and area code My e-mail address is: Best time to call is, am  pm: Pacific-time, Mountain-time, Central-time, Eastern-time: A). 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:       B). 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?       C). 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:        D). General Contact Information:  Your Relation to the Alcoholic/Addict: 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 ? Current drug (s) their using:       Question/Comment/How can we help you: Yaba drugs   Site Map   Link to us   Links   Contact us     ©2004 Free My Addiction Referral Services