Addiction Assessment Form
Please provide information about mental and physical addictions to help us understand your situation.
Full Name
*
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Addiction
*
Substance (e.g., alcohol, drugs)
Behavioral (e.g., gambling, internet, gaming)
Emotional/Psychological (e.g., anxiety, compulsions)
Other
How long have you been experiencing this addiction?
*
Please Select
Less than 6 months
6 months to 1 year
1 to 3 years
More than 3 years
How does this addiction impact your daily life?
*
Have you sought help before for this addiction?
*
Yes
No
Additional comments or details you'd like to share
Submit
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