Alcohol & Addiction Support | New Virtual Program Coming Soon!

Age *

Gender *

Education level *

Employment status *

Living situation *

Marital status *

Substance(s) you currently use *

Have you ever tried to quit? If so, what were the results? *

Has substance use impacted your physical and/or mental health? *

Has substance use impacted your relationships? *

Have you ever gotten into legal trouble due to substance use? *

What role, if any, does religion and/or spirituality play in your life currently? *

What are your reasons for wanting to change substance use? *

What are your goals for treatment? *

Is there anything else you would like to share about your substance use or your desire to change? *

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