Please provide some basic information which will help us better understand your needs. All information is held in a secure format absolutely confidentially.

* Required fields

Name of Client: (First, Middle, Last)*

Contact (if you are completing this form for someone else, please enter your name):

Email:*

Phone:*

Sex:*
Male Female

Describe the dependency, addictions and behavior to the best of your ability:*
Detox Needed? Yes ____ No_____      Is An Intervention Needed? 

Is the individual in treatment, or had treatment in the past. No Yes If yes, please explain below:
         Please give us an idea of when the patient may want to come into treatment? 

Please explain; current physical & emotional conditions: Stress/Panic Attacks, Obsessive Compulsive Behavior; Anger-Pain *

Is the individual taking any prescription medication: No Yes
If yes please specify dosage and frequency:

Why do you think there is a problem?: When and why do you think the problem began?   Patient's occupation is-