Get Help Now Please take a moment to fill out our online assessment form below and our cocaine addiction counsellor will get in touch with you shortly. Name : E-mail : Phone No. : Best Time to Contact : Please select your state : —NSWSAWAQLDNTTASVICACT Please select who you are contacting us for? —YourselfFamily memberPartnerFriend Is the addict abusing alcohol or other substances in addition to cocaine? yesno Method of administration : —SwallowingSmokingSnorting/sniffingInjecting How much cocaine is being consumed daily? How long has the addict been using cocaine? How old is the addict? At what age did use begin? Does the addict want help? yesno Has the addict ever been in a drug rehab? yesno Anti-Spam test :
