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!
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.
CURRENT LIFE STRESSES
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
NATURAL MOTHER HISTORY
NATURAL FATHER HISTORY