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We use Google G Suite's edition of Google forms designed for medical practices. All your information is encrypted to HIPAA standards for your privacy as you enter it and is stored in our secure cloud environment. Follow all the prompts to schedule your initial physician's video chat.
First, are you 21 or over (we can only treat clients 21 and over)?
*
Yes
No
Now, is your preference to stop drinking completely or to continue to drink but just cut back?
*
I would like to stop drinking completely.
I would like to continue to be able to drink but just cut back.
Are you not seeing the results you expected from other treatment methods, such as AA?
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Yes, everything else I've tried hasn't worked well and I want something that will work.
No, I haven't tried any other methods yet.
Do you feel drinking is contributing to weight gain and you would like to lose some weight?
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Yes, I feel drinking has contributed to weight gain and I'd like to cut back for that reason.
No, my weight doesn't seem to be affected from my drinking.
Do you see yourself as facing some limitations in your social life because you feel a need to avoid other people who drink alcohol, or avoid places where alcohol is present, and you would like to eliminate these restrictions?
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Yes, I'm hesitate to be with certain people or go certain places to avoid alcohol.
No, I'm able to be with others who drink and go places where alcohol is served.
Do you want to improve one or more relationships by cutting back or stopping drinking? This could be a social relationship or something more formal, such as an employment relationship.
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Yes, I'd like to cut back or stop drinking to improve one or more of my relationships with others.
No, my relationships are fine and I don't feel they have been affected much or at all from drinking.
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