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Drug Rehab Indiana Treatment Centers Referral Request First Name Phone (Home) Last Name Phone (Work) Email Address Phone (Cell) Best Time to Call am. pm. anytime Dependants Age Group choose 12 to 17 18 to 25 26+ Addicted Person self son daughter spouse father mother friend other If other then self please give addicts first and last name Addicts First Name Addicts Last Name Is addict seeking help? Yes No Main Drug of Choice Alcohol Cocaine Marijuana Meth Methadone Ecstasy PCP Speed Heroin LSD XTC Other Type of Treatment drug rehabilitation drug rehab drug treatment alcohol treatment drug addiction treatment drug abuse treatment substance abuse treatment heroin treatment cocaine treatment marijuana treatment crack treatment meth treatment ecstasy treatment addiction treatment other ... City Anderson Bloomington Elkhart Evansville Fort Wayne Gary Hammond Indianapolis Lafayette Muncie South Bend Terre Haute List any drug rehab or treatment centers the addict has previously attended. Describe the general situation at the present with the addicted person. Discribe addicted person's legal history. (current & past charges or incarceration} Any additional questions or comments Contact me by : Phone Home E-Mail Phone Work Phone Cell To submit this form you must type the following number in the box below