Detox Program Intake Assessment Questionnaire
Complete this intake assessment to share your goals, preferences, and readiness for a detox program. No sensitive health or compliance claims are included.
Client Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Text
Detox Assessment
Current Detox Goal
*
Start detox
Learn more
Ongoing support
Not sure yet
Areas of Concern Before Starting
Energy levels
Sleep routine
Stress management
Diet habits
Hydration
Physical activity
Other
Readiness to Begin
*
Not ready
1
2
3
4
Very ready
5
1 is Not ready, 5 is Very ready
Daily Habits and Wellness Areas
Rows
Needs Attention
Improving
On Track
Sleep
1
2
3
Nutrition
4
5
6
Hydration
7
8
9
Movement
10
11
12
Stress Management
13
14
15
Program Preferences and Notes
Preferred Start Timeframe
*
As soon as possible
Within 1 week
Within 2 weeks
Flexible
Additional Notes or Questions
Submit
Should be Empty: