Addiction Free Life Quiz

Fear It Goes

Addiction Free Life Quiz
Our Promise To You

All Information provided on this form is highly confidential and treated with the utmost respect. We share this with NO ONE. We do no SHAME, GUILT or JUDGE ANY ANSWERS you fill in below so please be as honest as possible with your answers. The sole purpose for this information is to understand your big picture, where you are currently and how where if any help you may need.
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Phone Number
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Imagine for a moment, if we could wave a magic wand what changes would you like to see in your life in the next twelve weeks? Don't hold back.
Check all that apply. When using something like drugs, alcohol, sex, adrenaline activities, gambling... Do you

Craving it a lotDon't feel ok when you don't use itCan't control of amount or frequencies of useFeel Compelled to use or do itWill use or do despite the consequences
How often do you find yourself using?

Multiple times a dayDailyA few times a weekA few times a monthOther
If you clicked other please use this space to elaborate.
On a scale of 1 through 5 do you find yourself using a substance or engaging in behaviours that become compulsive? Or continue using despite the potential for harmful consequences?

1

2

3

4

5

1 is Worst, 5 is Best
Do you feel you use or engage more than you want? Be 100% honest. Do you recognize any recurring triggers that make you want to use? If so, what are they, who are they with, and how are you adding to it? There is no judgment here, only details to get the larger picture. Please give details.
What is this costing you? Financially? Time? Energy? Emotionally? Physically?
What other solutions have you sought out in the past, and how well did they work for you? (ie. group, counsellors, therapists, coaches)
If you feel this is an issues, what are the biggest struggles you are facing with it now? The more details the better. (Are they affecting family relationships? Career? Friends? Living life or going into hiding?)
If you could change this, clear the desire to use or act out what would that mean for you and your life? Imagine for moment. Write everything you can think of that would improve. (Only include the way you would like to see your life not the reason why you are in it, we work through that in the process. This question is meant only for the improvements you see on the other side of these issues).
On a scale from 1-10 how committed are you living your most fulfilled life and clearing whats blocking you?
On a scale of 1 to 10, where would you rate your Deserving Self? Do you feel you deserve healing? A great life? A great family? Great friendships? A great career?
Would you like to discuss any help that may be available for you? If so please Our team will call you at the time you chose. Please commit to your appointment by typing this sentence in the box. "YES, I PROMISE TO ANSWER THE CALL TO MY ADDICTION FREE LIFE CALL" and add your phone number here.
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Fear It Goes

Our Promise To You