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Confidential Member On-boarding Questionnaire
First Name
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Last Name
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Email Address
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Date of birth
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How often and how much do you drink at the moment?
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Have you tried any other programs to help you with your drinking before? If so, which?
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When was the last time you took a break from drinking & how long for?
*
Have you ever experienced severe withdrawal symptoms like the shakes, hallucinations etc. when trying to quit?
*
Are you currently or have you ever suffered from serious mental health issues, suicidal thoughts and/or have you ever attempted suicide? If yes, please provide more information.
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Please provide us with your next of kin's name, phone number and email address (note: we will NOT contact your next of kin except in the case of an emergency.
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