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Please select the options below to view the services that are best suited for you.
Gender
*
Male
Female
Age
*
Under 11
11-17
18-25
26-older
Race/Ethnicity
African American
Alaskan Native
Asian
Caucasian
Hispanic
Native American
Native Hawaiian
Pacific Islander
Declined
Other
Who referred you for services?
Drug Court (Adult)
Agencies with Juvenile Justice
Safe Children’s Coalition
Child Protective Service
Self
Other
Other
How often have you used any of the following drugs?
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Alcohol
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Amphetamines
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Benzodiazepines
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Club Drugs
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Cocaine/Crack
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Crystal Meth / ICE
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Heroin
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Inhalants
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Marijuana
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Opiates
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Other
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Prescription Medication - Pain Pills
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Prescription Medication – other
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
Sedatives
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
NONE
Within past 2 days
3-7 days ago
1-4 weeks ago
1-3 months ago
4-12 months ago
More than 12 months ago
Never
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