Consent to Treatment form may be downloaded here.

Tell me a bit about you.

First Name

Last Name

Birth Date

Gender
MaleFemale

Address



Phone

Email

How did you hear about me?

Have you been in counseling previously?
YesNo

Are you currently attending meetings for recovery?
YesNo

If yes, how long?

What is it in your life you desire to change?

Have you read ”Ready to Heal“?
YesNo

How would you assess your readiness for change?
Extremely EagerEagerInterested in Knowing MoreHesitantNot really interested in changing: someone else wants me to change

Additional Remarks