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Initial Interview Form

Registration Step 1

Fill out this Initial Interview Form, and click 'Submit'.

Then, view 'Payment Options'.


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Family Life:

1. Describe your home life as a child. Was it happy, difficult, or a mix?
2. Do (or did) any of your parents, siblings, or spouse have a problem with drinking or drugging?
3. If yes, which substance(s)?

Alcohol Use:


1. How old were you when you first drank alcohol?
2. During your entire life, when you were drinking the most, what was/were your drink(s) of choice?
3. How many would you drink? How often would you drink. How long did you engage in this pattern?
4. Would you consider this pattern to be a mild, moderate, or severe use (or abuse) of alcohol?

Drug Use:

1. How old were you when you first used a non-prescribed drugs?
2. During your entire life, when you were using non-prescribed drugs the most, what was/were your drug(s) of choice?
3. For each drug, How much would you use? How often would you use. How long did you engage in this pattern?
4. Would you consider this pattern to be a mild, moderate, or severe use (or abuse) of the drug(s)?

Social Choices:

1. What is your favorite activity?
2. Where do you socialize the most?
3. What is most important to you?