Heroin addiction takes over your life.
It's time to take your life back
and make it yours.

You can put an end to
Heroin Addiction
Call (877) 340-3602

Heroin Addiction Confidential Assessment

First name *
Last Name
City, State *
Phone *
E-mail Address: *
Is this regarding you? *	yes no
If not, how are you connected/related to this person?
What is the age of the addict? *
Main Drug being used *
Second Drug being used *
Third Drug being used
Briefly describe this persons drug history
What problems has addiction caused the addict? *
What problems has the addiction caused the family?
What is the worst problem facing the addict?
Please describe briefly what the current scene is with the addict

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Overcome Heroin Addiction Starting Today
Help is Available at (877) 340-3602

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