*

Male

Female

Yes

No

*

Yes

No

*

Single

Married

Divorced

Separated

Widowed

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Good

Fair

Poor

Disabled

Yes

No

Yes

No

ADHD

Austism

Cerebral Palsy

Intellectual Disability

Hearing Loss

Learning Disability

Vision Impairment

Yes

No

Yes

No

Major Depression

Borderline Personality Disorder

Bipolar Disorder

Schizoaffective

Panic Disorder

Anxiety

Schizophrenia

Other

Yes

No

SSI/Disability

Laid Off

Unemployed

Student

Family/Friends Assist

Alcohol Never Use

*

Alcohol Currently Use

*

Marijuana Never Use

*

Marijuana Currently Use

*

Cocaine (Powder) Never Use

*

Cocaine (Powder) Currently Use

*

Cocaine (Crack) Never Use

*

Cocaine (Crack) Currently Use

*

Heroin Never Use

*

Heroin Currently Use

*

LSD (Acid) Never Use

*

LSD (Acid) Currently Use

*

Ecstasy Never Use

*

Ecstasy Currently Use

*

Methamphetamines Never Use

*

Methamphetamines Currently Use

*

Fentanyl Never Use

*

Fentanyl Currently Use

*

Other 1 Never Use

*

Other 1 Currently Use

*

Other 2 Never Use

*

Other 2 Currently Use

*

Other 3 Never Use

*

Other 3 Currently Use

*

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