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Your name:  
E-mail Address :  
Phone Number:  
Phone:  
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State:  
Contacting Synergy for:  
If contacing us on behalf of another, please tell us their name:  
Select Your Time Zone:  
Best Time to Call:  
     
    Drug and Alcohol History
Primary Drug of Abuse:  
Method of Intake  
Secondary Drug of Abuse:  
Method of Intake  
Age user began Drug use:  
How old is user now?:  
At what age did the users's life begin to become unmanageable?  
Current Problems
which are the result of the
user's condition: 		 
User's family's attitude towards the addiction:  
Does the user admit to having a problem.   yes  no 
Does the user want help?   yes  no
     
    Treatment History
How many times has user been in treatment for this addiction?  
How Many of These Involved The 12-Step (AA/CA/NA Model) Approach To Recovery?  
Was There Any Success With Any Of These Treatment Episodes, and if so, what was the length of sobriety achieved?  
     
    Medical History
Is the user on any medications?  
If So, Please Specify Medications Taken:  
Has The User Ever Had Seizures for Any Reason In The Past ?  
Is The User On Medication for A Psychiatric Disorder?  
If So, Please Specify Medications Taken:  
     
    Supplemental Background
Does the user
have legal issues? 		 
If so, please describe:  
     
Please provide us with any other information and any questions you may have:  
     
 


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