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60 DAY REALITY CHECK
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HOME
ABOUT
TESTIMONIALS
CONTACT
PROGRAMS
UNWANTED GROUP
60 DAY REALITY CHECK
BLOG
CART
New Client Questionnaire
Please answer the following questions to give us some basic details about your current state.
Name
Age
How did you hear about us?
Email
Marital Status
Children
Medications, medical conditions, or concerns
Methods for sobriety attempted in the past
Employment status
Religious background
TOBACCO / NICOTINE USE
Do not use
Use casually
Use excessively
Years
Comments
DRUGS (ANY AND ALL)
Do not use
Use casually
Use excessively
Years
Comments
ALCOHOL
Do not use
Use casually
Use excessively
Years
Comments
GAMBLING
Do not use
Use casually
Use excessively
Years
Comments
SUGAR / JUNK FOOD
Do not use
Use casually
Use excessively
Years
Comments
EXERCISE
Do not use
Use casually
Use excessively
Years
Comments
SHOPPING
Do not use
Use casually
Use excessively
Years
Comments
VIDEO GAMES
Do not use
Use casually
Use excessively
Years
Comments
PORN
Do not use
Use casually
Use excessively
Years
Comments
MASTURBATION
Do not use
Use casually
Use excessively
Years
Comments
SEX
Do not use
Use casually
Use excessively
Years
Comments
Please provide brief details on any other addiction issues
SUBMIT