New Life Recovery Centers, Inc.
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New Life Recovery Centers offers safe, sober and confidential treatment for drug and alcohol dependency.  Whether you personally suffer from a chemical or alcohol addiction or whether you are seeking help for a loved one, contact us:

New Life Recovery Centers, Inc.

Local Phone:     (408) 297-1182
Toll-Free:          (866) 894-6572
Fax:                 (408) 297-7450

www.newliferecoverycenters.com

Site Address
782 Park Avenue, Suite 1
San Jose, CA 95126

Contact Information

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Last Name:

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If Contacting Us For Someone Other Than Yourself, Please Enter Their Name:

Drug and Alcohol History

What Is The Primary Drug of Abuse?:

Method of Intake?:

How Often?:

Current Age of User?:

At What Age Did The User First Take Drugs?:

At What Age Did The User’s Life Begin To Be Unmanageable?:

Describe Current Problems or Concerns:

Does The User Admit To Having a Problem?:

Yes
No

Do You Or The User Want Help?:

Yes
No

Medical History

Please List Any Medical Conditions The User May Have.  Be Sure To Include Mental Health Diagnosis (if applicable):

List Any Prescribed Medications The User Is Taking?:

If The User Has Medical Insurance, Who Is The Insurance Carrier?:

Other Info

Does The User Have Any Current Legal Problems?:

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If There Are Legal Problems, Please Describe:

Please Provide Any Other Pertinent Information That You Feel Is Important:

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