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Please provide us with as much information as you possibly can.
All information is stored confidentially and will not be passed onto third parties without your consent.
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General Information |
Are you: |
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Your Name: |
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Client’s Name (if applicable): |
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Client’s relationship to you (if applicable): |
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Client's age: |
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Client's gender: |
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Client’s town and country of residence: |
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Please describe the problem in question:
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What is the pattern of use: |
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Please state substance used (if known): |
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Quantity used (if known): |
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Please state the length of time of use (if known): |
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Are you/the client experiencing any of the following side effects?:
Tremors and shakes, sweats, irrational behaviour, mood swings, anxiety or depression: |
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Do you/the client lie about the frequency and the amount of use |
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Is there a family history of addiction, alcoholism or depression |
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What is your available budget: |
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Do you have private medical insurance:
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Would you like to receive details from the various clinics:
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Which Search Engine did you use to find
First4Rehab: |
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Please provide us with any further information which you feel may assist us in efficiently handling your enquiry: |
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| Contact Details |
Telephone number:
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Email Address: |
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Please reconfirm your email address: |
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