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Intake form
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Name
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Email address
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What is your age?
What is your gender?
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Male
Female
Non-binary
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What substance(s) are you seeking help with?
Please select at least one option.
Alcohol
Prescription drugs
Illegal drugs
Tobacco
Other
Do you have a history of mental health disorders?
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Yes
No
If yes, please specify the disorders.
What is your current living situation?
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Independent
With family
With friends
In a group home
Have you previously undergone treatment for addiction or mental health issues?
Select
Yes
No
If yes, please provide details about your previous treatment.
What are your primary goals for recovery?
How did you hear about RewireMe recovery?
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Referral
Online search
Social media
Additional questions or comments
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