Do you feel like your cravings for any of the following occupy your thoughts to long or do you feel like it would be difficulty to stop any of these things completely:

Caffeine *

Yes

No

Alcohol *

Yes

No

Smoking/Vape *

Yes

No

THC *

Yes

No

Other drugs *

Yes

No

Gambling *

Yes

No

Gaming *

Yes

No

Other:

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First Name *

Last Name

Email *

Phone

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