Personal Questionnaire
Client Information
Name
Email
Phone
HOW CAN WE HELP YOU?
Are you currently struggling with an addiction of some sort?
Yes
No
Are you wanting to be freed of your addiction?
Yes
NO
Are you willing to follow the program to the end to get the results?
Yes
No
Are you in a crisis situation now?
Yes
No
How can we best help you gain theresults you are seeking?
HOW DID YOU HEAR ABOUT US?
Method
referral
direct mail
online add
sales call
yellow pages
print ad
Other
THANK YOU!
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