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?

Marital Status

Children

Medications, medical conditions, or concerns

Methods for sobriety attempted in the past

Employment status

Religious background

TOBACCO / NICOTINE USE

Years

Comments

DRUGS (ANY AND ALL)

Years

Comments

ALCOHOL

Years

Comments

GAMBLING

Years

Comments

SUGAR / JUNK FOOD

Years

Comments

EXERCISE

Years

Comments

SHOPPING

Years

Comments

VIDEO GAMES

Years

Comments

PORN

Years

Comments

MASTURBATION

Years

Comments

SEX

Years

Comments

Please provide brief details on any other addiction issues