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What substance(s) are you seeking Detoxification from? Please list amount/dosage and how often you use: |
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| Are you using any other substances? If so, please list how much and how often you use these substances: |
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| Please list any medications and supplements/vitamins you are presently taking or have taken in the past 6 months. Please also list what dosages and how often: |
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| Previous detoxification or treatment attempts? Please provide a detailed account of all other previous detoxification or treatment programs that you have been to, with some information on the outcomes of these other options (ie: why they did or didn't work) |
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| Have you participated in NA/AA? |
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| Do you participate in any counseling or other forms of therapy or support groups? |
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| Please describe what you do in your career, work or study: |
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| Please describe what your social support network is like (such as family, friends, co-workers): |
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Please describe your living environment, do you consider it to be healthy or unhealthy? |
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| Please describe your eating habits and your relationship to nutrition: |
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| Do you feel like you could use some assistance or counseling in learning more about nutrition? |
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| Physical Health/ Exercise patterns: |
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| Please describe your state of health |
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Sedentary (No exercise) |
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Mild Exercise (i.e., climb stairs, walk 3 blocks, golf) |
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Occasional Vigorous Exercise (i.e., work or recreation, less than 4x/week for 30 min.) |
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Regular Vigorous Exercise (i.e., work or recreation 4x/week for 30 minutes) |
| Please describe your usual withdrawal symptoms and list anything you have found to be helpful in alleviating these symptoms or improving how you feel: |
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| Have you ever been abstinent from the substance you are seeking to detoxify from? If so, how long did this period of time last and what did you do to maintain your abstinence?:
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| Please describe your plans for aftercare. List any aftercare options which appeal to you: |
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| How will you enjoy life without misusing substances? What kind of activities or hobbies bring you pleasure? |
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| How do you cope or deal with stress in your life? |
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| Please describe any potential triggers you think could compromise your recovery: |
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| Please describe any goals you have, what kinds of things motivate you in your recovery? |
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| Do you have any spiritual practices or beliefs?
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| Please provide us with a detailed history of your substance use |
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| Is there anything else you would like our staff to know about you? |
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| Have you ever taken a hallucinogen, psychedelic or entheogen? If so, please describe: |
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| Have you had any negative experiences or reactions to these? If so, please describe: |
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