Age       Ethnicity       

Gender male female trans gendered      Marital Status married partnered single       

Employment Status employed unemployed     

City       State       Zip Code

Are you looking for information for you or someone else?
me someone else both

What substances (cocaine, alcohol, etc.) or behaviors (gambling, sex, etc.) are being used or abused?
       Mode of entry oral intravenous (IV) intranasal (snort) intra muscular smoke anal huffing other
       Mode of entry oral intravenous (IV) intranasal (snort) intra muscular smoke anal huffing other
       Mode of entry oral intravenous (IV) intranasal (snort) intra muscular smoke anal huffing other
       Mode of entry oral intravenous (IV) intranasal (snort) intra muscular smoke anal huffing other
       Mode of entry oral intravenous (IV) intranasal (snort) intra muscular smoke anal huffing other
       Mode of entry oral intravenous (IV) intranasal (snort) intra muscular smoke anal huffing other

What is the frequency of use or abuse?
daily weekly 2 or 3 times a week every 2 weeks monthly

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If there has been prior treatment, what type?
outpatient inpatient detox recovery house

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Are you a professional?
attorney clergy counselor EAP counselor medical professional other police worker politician/ government probation social worker teacher/ school worker

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How did you hear about the help line?
ADHL advertisement card counselor crisis line family member flyer friend internet search legal/ court medical professional other phone book poster resource list school related teacher television treatment agency

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What kind of referrals are you interested in?
ADIS classes crisis service detox domestic violence DUI HIV/ AIDS/ STD housing inpatient treatment medical outpatient treatment substance abuse support groups teen call victim's panels

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Are you in an abusive relationship? psychological physical emotional

Who is being abused? you other

What role do you play abuser abused concerned other

Please help us document below what information would be most helpful for you.

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(Please note that we can not respond to any requests through this form at this time. This is only for data collection purposes. Please call 206-722-3700 or 800-562-1240 for 24 hour help.)