Drug Addiction Treatment Rehab Form

Drug Addiction Treatment Help Line
1-888-781-7060

<% =application(i) %>

Please fill in the confidential case assessment form below and we will contact you soon. If you need assistance immediately then dial the toll free number.

Name
Email Address
Home Phone #
Work Phone #
Phone # Cell
Best time to call  
Dependants age group
Seeking help for
If other than self please fill in Addict's first and last name
Addict's First Name
Addict's Last Name
Main Drug of Choice
Is Addict seeking help
List any Drug Treatment previously attended and if program was completed
Describe the general situation at present with addicted person
Describe addicted person's history (hospitalizations, psychiatric evaluations, present illnesses ect.)
Describe addicted person's legal history. (current & past charges or incarceration}
Type any questions or comments below and when completed click the Submit information below



Drug Addiction Treatment and Programs

We at Drug Addiction Treatment Help Line will respond to your request for help as soon as possible.

Thank You.


Heroin Addiction Treatment Heroin addiction falls under the heading of opiate addiction, which is the second leading addiction in our society; following alcohol addiction. Heroin is noted for having the highest euphoria potential of all opiates and is, therefore, prone to cause psychological addiction even if the user were to not become physically addicted. Heroin Addiction is defined as a state of physiological or psychological dependence on a drug liable to have a damaging effect.

Cocaine Addiction Treatment Even though many law enforcement policies and officials refer to cocaine addiction as a narcotic addiction, this is incorrect. Narcotics is a term used to refer to those substances that bind opiate receptors and produce morphine-like effects. This
includes the entire class of opiates and some other drugs as well. Cocaine addiction is the addiction to a stimulant. Derived from the coca leaves.

Crystal Meth Addiction Treatment Crystal Meth addiction and abuse has three patterns: low intensity, binge, and high intensity. Low-intensity abuse describes a user who is not psychologically addicted to the drug but uses crystal meth on a casual basis by swallowing or snorting it. Binge and high-intensity abusers are psychologically addicted and prefer to smoke or inject Crystal Meth to achieve a faster and stronger high. Binge abusers use crystal meth more than low-intensity abusers but less than high-intensity abusers.

Crack Addiction Treatment Cocaine is usually sold on the street as a fine white powder and is generally either sniffed into the nose or injected by needle into a vein, with the latter being the type of administration that is most common with cocaine addiction. When cocaine is boiled or cooked with sodium bicarbonate, it is converted into a freebase form called crack cocaine and is more addictive than before and is relatively cheap per dose.

Drug Addiction Treatment About Us | Site Map | Privacy Policy | Contact Us | © 2000 Addiction Treatment helpline