alcure signup
Email address *
We use Google G Suite's edition of Google forms designed for medical practices. All your information is encrypted to HIPAA standards for your privacy as you enter it and is stored in our secure cloud environment. Follow all the prompts to schedule your initial physician's video chat.
First, are you 21 or over (we can only treat clients 21 and over)? *
Now, is your preference to stop drinking completely or to continue to drink but just cut back? *
Are you not seeing the results you expected from other treatment methods, such as AA? *
Do you feel drinking is contributing to weight gain and you would like to lose some weight? *
Do you see yourself as facing some limitations in your social life because you feel a need to avoid other people who drink alcohol, or avoid places where alcohol is present, and you would like to eliminate these restrictions? *
Do you want to improve one or more relationships by cutting back or stopping drinking? This could be a social relationship or something more formal, such as an employment relationship. *
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This form was created inside of Report Abuse