Addiction Recovery Treatment Selection Form
Use this form to select and compare addiction recovery treatment options based on your needs and preferences.
What is your primary goal for addiction recovery treatment?
*
Achieve sobriety
Reduce substance use
Prevent relapse
Improve overall wellbeing
Other
Which type of treatment are you most interested in?
*
Inpatient (residential)
Outpatient (day program)
Telehealth/Virtual care
Support group only
Other
Which substances or behaviors are you seeking treatment for? (Select all that apply)
*
Alcohol
Opioids
Stimulants
Prescription medications
Gambling
Other
How important is it for you to have family involvement in your treatment?
*
1
2
3
4
5
Which features are most important to you in a treatment program? (Select all that apply)
*
Personalized treatment plans
Medical supervision
Flexible scheduling
Peer support groups
Holistic therapies
Other
How would you rate your readiness to begin treatment?
*
Not ready
1
2
3
4
5
6
7
8
9
Very ready
10
1 is Not ready, 10 is Very ready
Do you have previous experience with addiction recovery programs?
*
Yes
No
What is your preferred level of support?
*
One-on-one counseling
Group therapy
Self-guided resources
No preference
What is your preferred treatment setting?
*
At home
Clinic or facility
Hybrid (mix of in-person and virtual)
No preference
Please share any other preferences or comments regarding your treatment selection.
Submit
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