Heroin drug rehab

Heroin Drug Rehab

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

Verification Code:
Enter Verification Code: *

* Required

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


 

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