Name (not required, but appreciated)
Email (not required, but appreciated)
Question 1: What addictions are you or your loved ones currently experiencing? Tobacco Alcohol Meth Crack Cocaine Heroine Pharmaceuticals Food Shopping Pornography Gaming Sex Cutting Gambling Hoarding Other
Please describe "Other":
Question 2: What is the biggest obstacle preventing you or your loved ones from overcoming the addiction(s)? Fear Pain Money Work Child Care Something Else?
Please explain your selection (i.e. Fear of what?):
Question 3: How much do the addictions cost you or your loved ones per year? $500-$1,000 $1,000-$2,000 $2,000-$3,000 $3,000-$4,000 $4,000-$5,000 $5,000-$10,000 $10,000+
Question 4: Have any other options been explored in an attempt to conquer the addiction(s)? If so, please explain.
Question 5: Where do you see yourself (or your loved ones) in 6 months or even 6 years, if the addiction(s) are not overcome?
Question 6: Is there any other information you care to share or questions you would like to ask us?
You can do this.