Online Questionnaire

  • Contact Information

  • Date Format: MM slash DD slash YYYY
  • Addiction Information

  • (If self-referred or referred by someone other than a clinician, please tell us your source)
  • (Please specify which substances you are being treated for)
  • (Please list all substances, including alcohol, prescription and recreational drugs, you have abused in the currently and in the past. If applicable, please include the quantity, frequency and when the last use was for each substance)
  • Medical History

    (If applicable, are you breastfeeding?)
  • Patient Attestation

    By submitting this form, I certify that I have completed this questionnaire to the best of my ability. I agree to seek immediate help should my symptoms worsen or I experience an increase in suicidal thoughts, feelings or urges. I authorize a representative from Klarity Life to contact me to discuss treatment options for my condition(s). I also understand that the staff of Klarity Life may not start and maintain any prescribed treatment regimen if I am not currently under the care of a Professional or Program managing my addiction(s) and maintain such care until the completion of my course of treatment. I also consent to receiving emails from Klarity Life for marketing purposes and I may opt out at anytime in the future by unsubscribing from Klarity Life's marketing list.