››› admission form Your name:   Email:   Phone:   Address:   Country:   Person you wish to help? Self Other       If other, who are you concerned about: Name:   Relationship:       How old is the addict? years old.     Does the addict want help? Yes No           Please list drugs abused: Primary:   Second:   Third:             How does the addict obtain drugs?     Works Steals Deals Other           Please describe any personal or family problems the addict has:               Please describe any legal problems the addict has:               Please describe the overall behavior & condition of the addict:               Is there any diagnosed medical condition? (Please describe)               Is there any diagnosed mental disorder? (Please describe)               Did the addict on any medication for any of the above? Yes No Name:   How long:             Has the person ever attempted to stop using drugs before? Yes No     If so, please describe where?               How long took the treatment?               After leave the treatment, how long did the addict stay clean?               Is there anything else you would like us to know?