Name

First Name

Last Name

Birthday

YYYY

Phone

(###)

###

####

Email address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you currently in recovery from a substance addiction?

Yes

Have you had treatment for substance abuse in the past? If yes, then please tell me where below.

What was the end date of your last treatment?

How long did you abuse substances?

Please tell me a little about how you are working on your recovery. For instance are you going to 12 step meetings, meeting with a sponsor, or something else.

Do you think there is an emotional component to addiction?

Yes

Briefly tell me how emotions played a role in your addiction

Why do you think group therapy will benefit you?

What would you like to learn or how would you like to grow through group therapy?

Summary Block

This is example content. Double-click here and select a page to feature its content. Learn more

Featured

Etiam Ultricies

Donec id justo non metus auctor commodo ut quis enim. Mauris fringilla dolor vel condimentum imperdiet.

Vulputate Commodo Ligula

Commodo cursus magna, vel scelerisque nisl consectetur et. Donec id elit non mi porta gravida at eget metus.

Elit Condimentum

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Vestibulum id ligula porta felis euismod semper.

Aenean eu leo Quam

Quisque iaculis facilisis lacinia. Mauris euismod pellentesque tellus sit amet mollis.

Cursus Amet

Sed purus sem, scelerisque ac rhoncus eget, porttitor nec odio. Lorem ipsum dolor sit amet.

Pellentesque Risus Ridiculus

Vivamus pellentesque vitae neque at vestibulum. Donec efficitur mollis dui vel pharetra.

Porta

Praesent id libero id metus varius consectetur ac eget diam. Nulla felis nunc, consequat laoreet lacus id.