COACHING REGISTRATION

In order for us to be able to fully determine if you are a candidate for our coaching programs,  please fill out the following questionnaire to the best of your ability. We realize there is a lot of information and you may not remember or have access to all of it; do the best you can. If there is information you do not want in your coaching chart it is ok to refrain from sharing it.  Thank you!

CLIENT IDENTIFICATION
REFERRAL SOURCE
Do we have your permission to release information to the referring professional when it is appropriate?
MAIN PURPOSE OF THE CONSULTATION 

Please give a brief summary of the main problem and what your goals are for completing a sober program:

PRIOR TREATMENT FOR ADDICTION

Please include contact with other professionals, medications, types of treatment, etc.

MEDICAL HISTORY
CURRENT LIFE STRESSES
SCHOOL HISTORY
EMPLOYMENT HISTORY
MILITARY HISTORY
SEXUAL HISTORY

Answer only as much as you feel comfortable

ALCOHOL & DRUG HISTORY

Please list age started and types of substances used through the years and any current usage. Also, describe how each of these substances made you feel; what benefit you got from them.). These include alcohol (hard liquor, beer, wine), marijuana or hash, prescription tranquilizers or sleeping pills, inhalants (glue, gasoline, cleaning fluids, etc.), cocaine or crack, amphetamines or crank or ice, steroids, opiates (heroin, codeine, morphine or other pain killers), barbiturates, hallucinating drugs (LSD, mescaline, mushrooms), PCP

FAMILY HISTORY
NATURAL MOTHER HISTORY
NATURAL FATHER HISTORY