* Mandatory Fields

Agents Info:

    *Name:  

      Agency:

    *Phone #:      *Fax #: 

    *E-mail address: 

Client Info:

    *Name:    

    *DOB:       *Height?      *Weight?    

     *Sex?      Male Female

If your client has had an Alcohol and/or Drug problem, please answer the following:

1. Has your client ever been treated for:

            Alcohol and/or drug abuse:    No Treatment Alcohol Drug Alcohol and Drug       Dates?        

            Has there been a relapse?     Unknown Yes No    If yes, please list date?  

            Does your client presently use alcohol or drugs?   Yes No

            Please describe quantity / dates: 

2. Is your client a member of AA, NA or CA?     Unknown None AA NA CA

            Please describe: 

3. Has your client taken ANTIABUSE?     Unknown Yes No      

    Is she/he taking it now?    Unknown Yes No

4. Has your client ever been convicted of any driving offenses related to

    Drugs/Alcohol? Unknown Yes Bo

        Please describe: 

5. Does your client have any medical problems, including liver disease or elevated

    enzymes related to alcohol/drug abuse?   Unknown Yes No

        Please describe: 

6. Before treatment how long has your client used:  Alcohol?    Drugs?

        Please describe: 

        What Drug and Amount was used?   

        How Frequently?