Smack Foundation, Inc.

On-line Consultation

Please Fill in this form Completely *
All information provided is kept in the strictest Confidence as per the         

Federal HIPAA Guidelines
 Privacy Statement

Contact Information:

   *Last Name: * First Name:  *M.I.
   *Address:
   *City: *   State:  * Zip Code:
  * Country:
  * Daytime Phone:
   *Evening Phone:
   *Email :

  * Is this inquiry for yourself ?  yes  no

If not, please enter the name of the person you are concerned about:
Last Name: First Name: M.I.

   *What is this addicts relationship to you ?

Drug History:

 *Please indicate which drug(s) are involved in the problem:
 *Drug of Choice:  *Second Choice:  *Third Choice:
     

   *How were the drug(s) introduced into the body ?  
  Intravenous     Smoking     Snorting     Pills

   *What is the age of the addict ?

  *When did the addict start using drugs ?   

  *At what age did the addict exhibit behavior changes ?   

   *What were the changes ?   

   *Are there any major events contributing to this problem ?
  (For example: trauma, death, abuse, etc.)

   *Briefly describe the drug history of the addict.   

   *What problems has addiction caused the addict?

  * What problems has addiction caused the family? 

Treatment History:

  * Has the person ever undergone addiction treatment ?  yes  no

If so, when and where ?   

  * Was it a private program or a state-funded program ?
 private  state-funded

 *Was it a traditional 12-step program or another type ?  12-step  other

   *What effect did this treatment have ?   

Medical History:

   *Does the person have any known medical conditions ?  yes  no

If yes, please describe them:   

 *Has the person ever been diagnosed with a mental disorder ?  yes  no

If yes, please specify:

 *Did he/she receive medication for the disorder ?  yes  no

 If yes, what ?

How long was it taken ?

Legal History:

   *Does the person have any alcohol/drug-related legal situations ?  yes  no

If yes, please describe them:   

Other Information:

  * Does the addict express the desire to get off drugs/alcohol ?  yes  no

  * What is the highest level of education completed by the addict ?

  *Is there anything that would prevent the addict from receiving help ?

  * Please describe briefly what is going on with this person right now.
  Also add any other information that we should know (best time to call, etc):

  * Would you like to receive more information on addiction  yes  no

All information provided is kept in the strictest Confidence as per the 

Federal HIPAA Guidelines

      

We will contact you, by e-mail once we have processed your information

Disclaimer


This site does not provide a diagnosis of alcohol or substance abuse, alcohol dependence or any other medical condition.

 The information provided here cannot substitute for a full evaluation by a health professional, and should only be used as a guide to understanding your alcohol or substance use and the potential health issues involved with it.