Confidential Fact Find

Confidential Fact Find Questionnaire

Completing the following questions before or during your free initial consultation will enable us to discuss and set realistic goals and outcomes and use the most effective approach based on your individual needs and circumstances. The form is only used for the purpose of your treatment and will never be passed on to other parties. We will never share confidential client information with any third party including law enforcement or any government body.

Confidential Fact Find Questionnaire

* Indicates required field

Name *

First

Last

Gender *

Male Female Other / Prefer Not to Say

Date of Birth *

Phone *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

GP's Name *

GP's Address of Postcode *

Describe Your Addiction or Situation *

Describe the environmental or emotional triggers (i.e. when it's more frequent) *

What are the obstacles that prevent you from stopping this addiction? *

How much does this addiction cost you financially per week or month? *

Why is it a MUST for you to tackle this addiction? *

What are the long term consequences if you don't tackle this addiction? The worst case scenario? *

How would your life be better without this addiction? The more detail the better. *

I agree to receiving marketing and promotional materials

Submit