Initial Forms Initial Forms Step 1 of 3 33% Personal Information All information is completely confidential.Name* First Last Name You Would Like to be Called: Gender:* Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sobriety Date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mailing Address:* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email* Cell Number:*Best Time to Reach You:* Safe to text, email, and leave voicemail messages?* Yes No Children/Dependents: Children Residing With You? Occupation: Marital Status: Single Partnership Married Divorced Widowed Emergency ContactName* First Last Cell Number:*Relationship:* Addiction HistoryALCOHOL - Ever Used?* Yes No How Much and How Often?*First Use/Last Use?* MARIJUANA - Ever Used?* Yes No How Much and How Often?*First Use/Last Use?* OPIOIDS - Ever Used?* Yes No How Much and How Often?*First Use/Last Use?* AMPHETAMINES - Ever Used?* Yes No How Much and How Often?*First Use/Last Use?* COCAINE/CRACK - Ever Used?* Yes No How Much and How Often?*First Use/Last Use?* HALLUCINOGENS - Ever Used?* Yes No How Much and How Often?*First Use/Last Use?* PRESCRIPTION MEDICATIONS - Ever Used?* Yes No How Much and How Often?*First Use/Last Use?* OVER THE COUNTER MEDICATIONS - Ever Used?* Yes No How Much and How Often?*First Use/Last Use?* BENZODIAZEPINES - Ever Used?* Yes No How Much and How Often?*First Use/Last Use?* TOBACCO - Ever Used?* Yes No How Much and How Often?*First Use/Last Use?* OTHER - Ever Used?* Yes No How Much and How Often?*Description:* First Use/Last Use?* Coaching QuestionnaireWHAT DOES THE WORD SOBER MEAN TO YOU?WHAT DOES HEALTHY RECOVERY LOOK LIKE FOR YOU?HAVE YOU TRIED TO GET SOBER IN THE PAST? IF SO, WHAT HAPPENED?WHAT IS MISSING FROM YOUR LIFE THAT WOULD HELP YOU FEEL FULFILLED?WHAT FEARS DO YOU HAVE ABOUT STAYING SOBER LONG-TERM?IS THERE ANYTHING ELSE I SHOULD KNOW ABOUT YOU?
