Detox intake & Assessment Form

Please take your time and fill out this Intake and Assessment with as much detail as possible. It will help me serve you better in our Detox Experience!
This form is private between you & I. It will not be shared in the group unless YOU choose to share from it. The more detailed and honest you are in filling this out, the more I can help you in this program!

Name *
Name
How do you feel overall everyday? (List all symptoms you feel on a daily basis) *
Check all symptoms that apply.
Please be honest and detailed! It helps me to help you and there is NO wrong answer here!
(ie what do you see yourself achieving or overcoming through this experience?)