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.
Email address *
1) Client Willingness *
2) Drug/s of choice *
Your answer
How long using? *
Your answer
How Much? (quantity and /or how much spent /week) *
Your answer
Frequency? *
Your answer
3) Any previous treatment received? (counseling, rehab, when, how long, where, etc.) *
Your answer
4) Dramatic and/ or Blockbuster event. (reason/s for the inquiry) *
Your answer
5) Perceived Challenges in Pursuing this initiative. ( i.e. Resources, stigma issues, legal, etc.) *
Your answer
6) Strengths (what you have that will make this happen) *
Your answer
7) If you decide to pursue this, who will the focal person with Serenity(from the family) – project director? *
Your answer
Any other concerns/questions/feedback?
Your answer
Thank you for your response. Please press submit to complete this form.
This form will be sent to serenitysteps2016@gmail.com. Please expect a reply, or follow-up email regarding your response. Please do not hesitate to contact us again!
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