Full Name
Date of birth
Phone
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Email
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Gender
Male
Please select the issues you are seeking treatment for: (select all that apply)
drug/substance use
alcohol abuse
anxiety
depression
trauma/PTSD
inability to cope with life
inability to transition back to real life after treatment
other addictions
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What are your main goals and expectations for participating in the Mountain Valley Recovery program? (select all that apply)
Be able to control my addictions
Rebuild my life
Learn to be a functional member of society
Rebuild my family/friend relationships
Learn skills to help me get a job
Receive therapeutic treatment for mental health struggles.
Other
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Are you currently taking any medications?
Yes
No
Please Specify
Do you have any medical conditions or allergies we should be aware of?
Yes
No
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How did you hear about Mountain Valley Recovery?
Friend/Family Member
Online Search
Facebook Ads
Referred by therapist
Referred by outpatient center
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Are you dependent on insurance to pay for the cost of treatment?
Yes
No
Is there anything else you would like to share with us or any specific concerns you have?
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No
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