Full Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Gender:
Male
Female
Marital Status:
Please Select
Single
Married
Divorced
Widowed
Other
If Other please specify
Employment Status:
Please Select
Employed (full-time)
Employed (part-time)
Unemployed
Self-employed
Student
Retired
Have you previouly sought treatment for substance abuse?
Please Select
Yes, Long term treatment
Yes, Short term treatment
No
Please select the issues you are seeking treatment for: (select all that apply)
drug/substance use
alcohol abuse
anxiety
depression
trauma/PTSD
inability to cope with life
inability to transition back to real life after treatment
other addictions
What are your main goals and expectations for participating in the Mountain Valley Recovery program? (select all that apply)
Be able to control my addictions
Rebuild my life
Learn to be a functional member of society
Rebuild my family/friend relationships
Learn skills to help me get a job
Receive therapeutic treatment for mental health struggles
Other
If Other please specify
Are you currently taking any medications?
Yes
No
If Yes please specify
Do you have any medical conditions or allergies we should be aware of?
Yes
No
If Yes Please Specify
How did you hear about Mountain Valley Recovery?
Friend/Family Member
Online Search
Facebook Ads
Referred by therapist
Referred by outpatient center
Are you dependent on insurance to pay for the cost of treatment?
Yes
No
Is there anyting else you would like to share with us or any specific concerns you have?
Yes
No
If Yes Please Specify
***Note:
All information provided in this questionnaire will be kept confidential and used solely for assessment and program planning purposes. Please ensure that you provide accurate and honest information to help us better understand your needs and tailor our program to support your recovery journey. Thank you for entrusting us with your care. You will receive an email with your results and be contacted by a member of our admissions team
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