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First Name:

Last Name:

Email Address:

Phone Number:

Alternative Phone:

State:

You are contacting Odyssey House of Utah for:

If you are contacting Odyssey for someone other than yourself, please enter their name here:

Select your time zone:
Preferred method of contact:

If you prefer to be contacted by phone, please provide the best time to call:

What is the drug(s) of abuse?
Alcohol 
Cocaine 
Crack 
Heroin 
Methamphetamine 
GHB 
Ecstacy 
Inhalants 
Katamine 
Prescription pain pills 
Benzodiazepines 
PCP 
Marijuana 
LSD 
Other drug 
Eating disorders 

Drug History

At what age did the user first take drugs?

How old is the user now?

What are the resulting problems of the user's addiction?

What is the family's attitude toward the person's addiction?

 

Does the person admit to having a problem?
Yes  No 
 
Does the person want help?
Yes  No 
 
Is the person willing to leave his/her home area to get the best treatment available?
Yes  No 
 

Psychiatric History

Has the person been diagnosed with any mental health problems?
Yes  No 
 

If yes, please list the conditions and any necessary details:

 

Medical History

Has the person been diagnosed with any medical problems?
Yes  No 
 

If yes, please list the conditions and any necessary details:

Legal History

Does the person have legal issues?
Yes  No 
 

If yes, please describe:

 

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