Briefly Describe the drug history of the addict:
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| What problems has addiction caused the addict?
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| What problems has addiction caused the family?
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| What kind of help do you think the addict needs?
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| What is the worst problem addiction has caused the addict?
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Other Information: |
Please describe briefly what is going on with this person right
now. Please add any other info you think we should know (i.e. best
time to
call)
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*Would you like to receive more
information on addiction?
Yes No
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