SUBSTANCE NAME
 YES,
USED
 NO, NEVER
USED
 YEAR OF
FIRST
USE?
 MONTH &
YEAR OF LAST
USE
 METHOD? (i.e., snort,
smoke, inject)
 IS THIS YOUR
PREFERRED
SUBSTANCE?
Alcohol
            
Marijuana
            
Pain Pills (i.e., Ultram,
Vicodin, OxyContin,
Demerol, Percocet,
Darvocet, etc.)
            
Benzodiazapines /
Tranquilizers  (i.e., Xanax,
Ativan, Klonopin, Serax,
Valium, etc.)
            
Powder Cocaine
            
Crack Cocaine
            
Heroin
            
Suboxene
            
Methadone
            
Hallucinogens (i.e., acid,
PCP, mushrooms, etc.)
            
Crystal Meth
            
Solvents (Please specify:
i.e., "wet," gasoline, glue,
etc.)
            
Special K / Ketamine
            
Ecstasy
            
Other (Please Explain)
            
Recovery-Based & Substance-Free Transitional Living in Pittsburgh-Area 3/4
Way Houses / Sober Houses for Women & Men
Intake Forms & House Rules can be opened &
printed from the links below
New Promises Foundation, Inc.