Lighter Fuels Paint Spray Stimulants: Cocaine Cocaine Crack Ice Meth Nicotine- Cigars Tobacco: Cigarettes Snuff Caffeine Energy drinks Coffee Ritalin Amphetamine Mescaline Speed Other: What is your drug of choice: __________________________________________________________________ of the following areas have been negatively affected by your use: School Attendance Family Relationships Physical Health    Employment Psychological Health Situation Other:____________    Do you think you have an alcohol and/or drug use problem? Yes No   Are others concerned your alcohol &/or drug problem? Yes No   Have you ever attended Narcotic &/or Alcoholics Anonymous meetings (AA or NA)? Yes No   If Yes, did you have an AA/NA sponsor? Yes No   Number of AA or NA meetings attended in the past 6 months: _____________ Do you have any following addictions?
Stimulants: Lighter Fuels Paint Spray Cocaine Cocaine Crack Ice Meth Nicotine- Tobacco: Cigars Cigarettes Snuff Caffeine Energy drinks Coffee Ritalin Amphetamine Mescaline Speed Other: What is your drug of choice: __________________________________________________________________ of the following areas have been negatively affected by your use: School Attendance  Family Relationships  Physical Health  Employment  Psychological Health  Situation  Other:____________ Do you think you have an alcohol and/or drug use problem? Yes  No  Are others concerned your alcohol &/or drug problem? Yes  No  Have you ever attended Narcotic &/or Alcoholics Anonymous meetings (AA or NA)? Yes  No  If Yes, did you have an AA/NA sponsor? Yes  No  Number of AA or NA meetings attended in the past 6 months: _____________ Do you have any following addictions?
APPLICATION_FOR_SERVICES.docx