Full Intake Information

Help us serve you better

Name *

Email address *

Message

What is your current living situation?

What substances are you struggling with?

Please select at least one option.

Alcohol

Prescription Drugs

Illicit Drugs

Tobacco

How long have you been struggling with this issue?

Have you previously sought help for this issue?

What type of support are you looking for?

Please select at least one option.

Individual Counseling

Group Therapy

Family Support

Educational Resources

Have you had any previous treatment?

If yes, please specify the type of treatment received.

Are you currently taking any medications?

If yes, please list the medications.

Do you have any medical conditions we should be aware of?

What are your goals for recovery?

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The Guided Recovery