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Are you interested in The Commonwealth Addiction Method for yourself or another person?
SELF ANOTHER

How old is the potential patient?
UNDER 18 18-25 26-35 36-45 46-55 56-65 OVER 65

To what is the potential patient addicted?
HEROIN METHADONE PRESCRIPTION OPIATE PAINKILLERS OTHER

If you are not the potential patient, what is his/her relationship to you?
SPOUSE/SIGNIFICANT OTHER CHILD PARENT OTHER FAMILY MEMBER FRIEND PATIENT CLIENT EMPLOYEE/CO-WORKER PARISHONER OTHER

How did you learn about Commonwealth Addiction?
INTERNET TELEVISION ADVERTISEMENT RADIO ADVERTISEMENT NEWSPAPER/MAGAZINE AD NEWS STORY ON TV, IN NEWSPAPER, OR MAGAZINE FROM A FRIEND OTHER

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