Medical questionnaire
Email address *
All your responses are kept strictly confidential and none of your information is shared or stored anywhere else other than within our HIPAA compliant electronic health record system. Let's get started with an idea of your treatment goals.
First, are you 21 or over (we can only treat clients 21 and over). *
And, what state do you reside in? *
Your answer
Is your preference to stop drinking completely or to continue to drink but just cut back? *
Do you see yourself as having a challenge in stopping to drink once you start and you want to regain control over being able to stop? *
Are you not seeing the results you expected from other treatment methods, such as AA, and are ready for a new and science-based approach with a proven, high success rate? *
Do you feel drinking is contributing to some weight gain and you would like to lose some weight by cutting back? *
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, such as parties, events, weddings, restaurants, dates, brunches or bars, 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. *
Never submit passwords through Google Forms.
This form was created inside of Report Abuse - Terms of Service