Drug Abuse Foundation

Contact By Email?

Date Of Birth *

Race*

Age *

Sex Male Female

Were you referred by someone?

Do you authorize DAF to communicate with someone from the referring agency?

Are you Homeless ?

Primary Drug Used

Method

Drug Used Last Date

Drug Used Last Time

Have you ever used Opioids ?

Method

Opioids Last Used Date

Opioids Last Used Time

Are you currently being treated for any physical health issues ?

Are you pregnant ?

Have you given birth in the last 3 months?

Check Set Appointment or Callback

Set An Appointment ?

Request a Callback ?

Contact Agency for Callback ?

Client Authorize ?

*If You Need Detox or Emergency Services.Please Go Directly To A Hospital Emergency Room Or To Emergency Receiving Center At DAF.

*Authorize DAF to process the request.