Name
*
First Name
Last Name
Email Address
*
Phone
Country
(###)
###
####
You are contacting Inspiro Recovery for:
*
Self
Family Member
Husband
Wife
Friend
Employee
Patient
Client
Other
If contacting us for someone other than yourself, please enter their name:
*
What is the primary substance of abuse?
*
Alcohol
Cocaine
Crack
Heroine
Methamphetamine
Ecstasy
GHB
Inhalants
Ketamine
LSD
Marijuana
Methadone
PCP
Prescription Drugs
Other
Method of Intake?
*
Unsure
Smoked
Snorted
Orally
Intravenous
What is the secondary drug of abuse?
Alcohol
Cocaine
Crack
Heroin
Methamphetamine
Ecstasy
GHB
Inhalants
Ketamine
LSD
Marijuana
Methadone
PCP
Prescription Drugs
Other
At what age did the user first take drugs?
*
How old is the user now?
*
What is the family's attitude toward the user's addiction?
*
Does the user admit to having a problem?
*
Yes
No
Does the user want help?
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Yes
No
How many times has the user been in treatment for their addiction?
*
How many of these involved a recovery support program, such as 12-Step, SMART Recovery, etc.?
*
Was there any success with any of these treatment episodes, and if so, what length of sobriety was achieved?
Does the user have any known medical conditions?
*
Yes
No
If so, please list the conditions and any essential details:
*
Has this person every been diagnosed with any psychiatric disorders?
*
Yes
NoIf
If so, is he/she currently on medication for a psychiatric disorder?
*
Yes
No
If so, please specify the medications taken:
Does the user have medical insurance?
*
Yes
No
If so, who is the insurance carrier?
Does the user have legal issues?
*
Yes
No
If so, please describe:
Please provide us with any other information and any questions you may have in the area below:
