Holistic Addictions Intake Form

Your journey matters. Providing this information helps us offer compassionate, tailored care that honors your individual life experiences.

What brings you here right now? *

Identify core behaviors/substances *

Timeline of your current struggle *

Are you currently in any therapy? *

Summary of previous recovery work *

List of current prescriptions *

Have you experienced safety risks? *

What positive outcomes do you hope for? *

Any other thoughts for your coach

MD Name *

Clinic or medical center