Steps to Serenity Initial Screening
Please answer the following honestly. This form will require 2-5 mins of your time. Thank you for your cooperation. Your name, contact number, and email address will be recorded for contacting purposes.
Email address *
Your First and Last Name *
Contact Number/s *
You will receive a text message or email from a Serenity Advocate to acknowledge receipt of this form. Thank you.
Who will receive the care? *
Name of Person who will receive care (if not yourself)
1) Client Willingness *
2) Drug/s of choice *
How long using? *
How Much? (quantity and /or how much spent /week) *
Frequency? *
3) Any previous treatment received? (counseling, rehab, when, how long, where, etc.) *
4) Dramatic and/ or Blockbuster event. (reason/s for the inquiry) *
5) Perceived Challenges in Pursuing this initiative. ( i.e. Resources, stigma issues, legal, etc.) *
6) Strengths (what you have that will make this happen) *
7) If you decide to pursue this, who will be the focal person, from your family (if applicable), with Serenity? *
Any other concerns/questions/feedback?
Please contact Jouel Brown +63 977 097 5051 to confirm that you have filled out this form, or send a follow-up email to serenitysteps2016@gmail.com *
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