Intake form

Name *

Email address *

What is your age?

What is your gender?

What is your primary reason for seeking treatment?

Please select at least one option.

Substance Addiction

Alcoholism

Mental Health Issues

Co-occurring Disorders

Have you previously undergone any form of treatment?

If yes, please specify the type of treatment received.

How long have you been struggling with addiction?

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

Are you currently taking any medications?

If yes, please list the medications.

What is your preferred method of treatment?

Please select at least one option.

Detox

Outpatient Care

Inpatient Treatment

After-Care

What is your availability for outpatient therapy sessions?

Please select at least one option.

Weekdays

Weekends

Evenings

Mornings

Do you have any support systems in place (family, friends, etc.)?

If yes, please describe your support system.

Which service or services are you interested in?

Please select at least one option.

Detox

Outpatient care

Inpatient residential

After-care

Additional questions or comments

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