Drug Treatment Centers
Drug Treatment Centers Washington
Please fill-out the form below so we can assess and refer your information to the treatment center which best suits your needs. Code 42 of Federal Regulations forbids parishioners to disclose the identities of persons inquiring about drug rehab services - even if they are never admitted to the facility.
Day Phone #: Evening #:
Best Time to Call:
Your Relation to the Alcoholic/Addict:
City: State: Zip Code:
If Other Please Specify:
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:A). 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:B). Family History:
Does anyone in the alcoholics/addicts immediate (blood) family have/or had a substance abuse problem? yes no
Any losses (death) or departures (divorce-separations) from the family institution?Ethnic/cultural background:
C). Social History
(Alaskan or Indian)
Any children? yes no
who has parenting responsibilities?
Has the individual enjoyed any social activities in the past? (if yes, specify)
Has there been a gradual shift to non-involvement in those activities? (if yes, when)
Has the individuals peer structure changed? yes noD). 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?E). Educational History:
Highest grade completed in grade school :
Vocational Tech? yes no
Any desire or plan of continued or future education?F). Occupational History
Occupation: How Long?
Is this the individuals chosen occupation? yes no
If no what is?
Has the individual ever been terminated as a result of substance abuse? yes noG). 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:H). Psychological and Behavioral History:
Has the individual ever been diagnosed and treated for any psychological or emotional problems? yes no
If yes, please specify what and when and outpatient or inpatient;
Was the individual prescribed medication for any psychological/emotional problem ? yes no
If yes, please list what drugs where prescribed and length of use:
On a Scale of 1-10, with 10 representing extreme urgency, and 1 representing information for later use. Please assign a number to this request :
Additional Information or Comments
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