GOODNEWS | Rehab Consultation

Please fill out this short questionnaire to provide some background information about you and the issues you'd like to deal with. It would help us match you with the most suitable medical consultant for you. Your answers will also give the consultant a good starting point.

What type of specialist are you looking for?

Rehab

What is your gender identity?

Male

Female

Non-binary

Prefer Not To Say

Do you have any pre-existing or current medical conditions

Yes

Are you currently taking any medication?

Yes

Do you have any known allergies ?

Yes

Have you ever been diagnosed with a mental health disorder?

Yes

Do you have any family medical history of serious conditions?

Yes

What substances have you used before?

You can select multiple options or just one

Alcohol

Prescription Drugs

Illegal Drugs

Other

How long have you been using substances

How often do you use ?

Daily

Weekly

Monthly

Occassionally

Have you experienced any of the following signs and symptoms?

You can select multiple options or just one

Increased tolerance

Withdrawal symptoms

Cravings

Loss of control over use

Neglecting responsibilities

Relationship problems

Legal issues

Health problems (physical or mental)

What are your primary reasons for seeking rehab?

You can select multiple options or just one

Desire to stop using substances

Health concerns

Relationship issues

Legal problems

Have you been to rehab before?

Yes

What type of treatment have you received previously?

What are your goals for treatment?

Are you interested in participating in support groups?

Yes

If yes, which types of support groups are you interested in?

You can select multiple options or just one

12-Step Programs (e.g., AA, NA)

Non-12-Step Programs

Group Therapy Sessions

Family Support Groups

Do you have any previous experience with support groups?

Yes

What is your preferred consultation type ?

In-Person

Online/Virtual

Do you have any specific concerns or questions?

Do you have health insurance?

Yes

Insurance Provider ?

Insurance Provider Policy Number?

Additional Comments?

Which country are you in?

Which language do you prefer?

Emergency Contact Information

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About Us

Help us match you to our Rehab Program

What type of specialist are you looking for?

What is your gender identity?

Do you have any pre-existing or current medical conditions

Are you currently taking any medication?

Do you have any known allergies ?

Have you ever been diagnosed with a mental health disorder?

Do you have any family medical history of serious conditions?

What substances have you used before?

How long have you been using substances

How often do you use ?

Have you experienced any of the following signs and symptoms?

What are your primary reasons for seeking rehab?

Have you been to rehab before?

What type of treatment have you received previously?

What are your goals for treatment?

Are you interested in participating in support groups?

If yes, which types of support groups are you interested in?

Do you have any previous experience with support groups?

What is your preferred consultation type ?

Do you have any specific concerns or questions?

Do you have health insurance?

Insurance Provider ?

Insurance Provider Policy Number?

Additional Comments?

Which country are you in?

Which language do you prefer?

Create an account to continue

Emergency Contact Information