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By
Drug Abuse Advisor
|
October 27, 2009
My Fieldset
First Name*
*
Last Name*
*
Phone*
*
Email*
*
Zip Code*
*
User Is*
Please Choose...
Self
Friend
Husband
Wife
Parent
Child
Loved One
Patient
Other
*
User Has Insurance?
Please Choose...
Private PPO Insurance
Private HMO Insurance
Medicare
Medicaid
Tricare (Military)
Other
Not Sure
User Does Not Have Insurance
User Has Money to Pay For Treatment?
Please Choose...
$1,000-$3,000
$3,000-$6,000
$6,000-$12,000
$12,000-$20,000
Greater than $20,000
Not Sure
User Does Not Have Money
What Substances is the User Abusing?
Please Choose...
Alcohol
Prescription Drugs
Recreational Drugs
Two of the above
All of the Above
What Substances is the User Abusing?
Please Choose...
Alcohol
Prescription Drugs
Recreational Drugs
Two of the above
All of the Above
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