(a) Please indicate the types of patients treated:

1. (1) Inpatient:

   1. (i) Adult.
   2. (ii) Adolescent.

2. (2) Ambulatory:

   1. (i) Adult.
   2. (ii) Adolescent.

(b) Please indicate the type of unit you have:

1. (1) Inpatient:

   1. (i) Detoxification.
   2. (ii) Maintenance.

2. (2) Ambulatory:

   1. (i) Detoxification.
   2. (ii) Maintenance.

(c) Please provide the following statistics:

1. (1) Inpatient:

   1. (i) Number of beds.
   2. (ii) Number of admissions during the reporting period.
   3. (iii) Number of patient days during the reporting period.

2. (2) Ambulatory:

   1. (i) Register of patients on last day of reporting period.
   2. (ii) Total number of different patients treated during the reporting period.
   3. (iii) Total number of visits during the reporting period.