Please fill out the form below, providing as much detail as you are comfortable with. A Project ADAM Addiction Counselor will contact you within 48 hours.

Name

First Name

Last Name

Phone

(###)

###

####

Are you currently incarcerated?

Yes

Address

Please type your full address here. Type the institution name if you are currently incarcerated.

Sex

Date

YYYY

Marital Status

Do you have children? How many? Are you currently paying child support?

Do you have clothes? If not, what sizes do you wear? (include shirt, pant, shoe & other relevant sizes)

Do you have any pending court cases? If yes, please describe.

Are you currently taking medication? If so, what kind and how much?

Please describe your primary problem and any treatment you have received in the past.

Are you currently in need of detox?