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I Am Seeking Info/Treatment for...*

  • Myself
  • My Friend
  • A Loved One
  • My Patient
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What type of treatment are you seeking?

  • Residential Treatamnet
  • Outpatient Treatment

Do you feel out of control when using drugs?

  • Often
  • Sometimes
  • Never

Do you use even when you don't want to?

  • Often
  • Sometimes
  • Never

Do you ever lie about how much you use?

  • Often
  • Sometimes
  • Never

Have you ever been arrested for drug use?

  • Often
  • Sometimes
  • Never

Have you ever overdosed on drugs?

  • Yes
  • No


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