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Name
State
Email
Phone
How do you prefer to be contacted?	Select Telephone Email Telephone and email
Best time to call
User needing the intervention	Select Self Husband Wife Daughter Son Sister Brother Parent Friend Others
Alcohol/drug problem	Select Alcohol Cocaine Crack Ecstacy Hallucinogens Heroin Marijuana Methamphetamine Morphine Opium Oxycontin Prescription drugs Others
Age of User
Brief alcohol/drug history
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