Intake Form

Complete and submit this intake form to help us understand how we might be able to help you and your family

* Required

Email address *
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Name *
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Address *
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Phone Number *
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What is your relationship to your loved one who is struggling? *
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What do you think or know they are using—drugs, alcohol? Please specify what and how much, if you know. *
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Please describe your current challenge. *
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Who does your loved one live with? *
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Do they drive a car? *
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Do they have children? If so, what are their ages and who do they live with? *
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What are you wanting to have happen for your loved one at this time? 
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What are you wanting to have happen for you at this time? 
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On a scale of 1-10, 10 being the highest, how committed are you to taking new action that is suggested to foster recovery for your family? *
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Specifically, how are you hoping we can help you at this time? 
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A copy of your responses will be emailed to the address you provided

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