Alcure signup

Email *

We use Google Workspace Forms for Medical Practices. All your information is encrypted to HIPAA standards as you enter it and stored in our secure servers with Google Cloud.

Let's confirm that you're 21 or over (we can only treat clients 21 or over). *

Yes, I'm 21 or over.

Is your preference to stop drinking completely or to continue but just cut back? *

I would like to stop drinking completely.

I would like to continue to drink but just cut back.

You're not seeing the results you expected from other self-restraint treatment methods such as AA or moderation management? *

Everything else I've tried hasn't worked well and I want something that will work.

I haven't tried any other methods before.

Do you feel drinking is causing weight gain and you would like to lose some weight? *

Yes, and that's a reason I'd like to cut back or quit.

No, my weight doesn't seem to be affected from my drinking.

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? *

Yes, I'm hesitate to be with certain people or go certain places to avoid alcohol.

No, I'm able to be with others who drink and go places where alcohol is served.

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. *

Yes, I'd like to cut back or stop drinking to improve one or more of my relationships with others.

No, my relationships are fine and I don't feel they have been affected much or at all from drinking.

Never submit passwords through Google Forms.

This form was created inside of Alcure.com. Report Abuse

Forms