RECOVERY SERVICES REQUESTED
InterventionRecovery CoachingTreatment Location ServicesSober TransportSober CompanionshipE-Recovery CoachingFailure to Launch Programs

YOUR NAME

CLIENT NAME

EMAIL

BEST TIME TO CONTACT

PREFERRED CONTACT METHOD
EmailTextPhone Call

DESIRED DATE TO BEGIN SERVICES

ADDICTION TYPE
PLEASE SELECT ALL THAT APPLY
ALCOHOLDRUGSPRESCRIPTION DRUGSEATING DISORDERC0-DEPENDENCYGAMING

PAST OR CURRENTLY EXPERIENCING
DEPRESSIONANXIETYOBSESSIVE COMPULSIVE DISORDEROTHER PSYCHOLOGICAL DIAGNOSIS (BI-POLAR, BORDER-LINE PERSONALITY, SCHIZOPHRENIA)
BRIEF BACKGROUND OF LOVED ONE

MALEFEMALEHAS ADMITTED ADDICTIONHAS AFFECTED RELATIONSHIPSHAS AFFECTED EMPLOYMENTHAS LOST DRIVERS LICENSEHAS BEEN UNABLE TO BE SELF SUPPORTINGHAS BEEN IN HOSPITAL DUE TO ADDICTIONHAS ATTEMPTED SUICDEHAS HAD INTERVENTION IN THE PASTHAS ATTEMPTED SOBRIETYHAS BEEN TO TREATMENTHAS BEEN TO JAILHAS OUTSTANDING LEGAL ISSUES

DESCRIPTION OF SITUATION

AGE OF LOVED ONE

LOCATION AND TYPE OF TREATMENT CENTER

AS YOUR INTERVENTION TEAM, WE WILL PROVIDE SUGGESTIONS AND MAKE ARRANGEMENTS

PERSON OF CONCERNS ADDRESS

ALL SERVICES ARE DESIGNED PER FAMILY SITUATION. IF YOU HAVE OTHER DETAILS SUCH AS A PROFESSIONAL, RELIGIOUS OR SEXUALITY PREFERENCE CONCERNS WE ACCOMODATE SO ALL PARTIES ARE COMFORTABLE. PLEASE LIST ANY ADDITIONAL INFORMATION.

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