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Please fill out the form below to help us determin how to correctly approach the problem at hand.

Last Name:
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Can we leave a message at this number? yes no
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Is this inquiry for yourself? yes no
Please indicate which drug is the primary problem
What is the age of the individual needing treatment?
Have they made an attempt to stop using drugs before? yes no
Has the individual attended a drug rehab before? yes no
Do they express the desire to get off drugs? yes no