First Name

Last Name

Date of birth

Email *

Phone *

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Do you have a family with small children at home that rely on you to care for them each day? *

Yes

Do you have a part-time or a full-time job that makes it difficult for you to take extended period of time off from work in order to go to addiction treatment at an inpatient facility? *

Yes

Are you able to stop using drugs or alcohol for a period of up to 3 days at a time on your own? *

Yes

Do you feel that you have a solid support system that will help you get through each stage of your addiction recovery? *

Yes

Do you feel that you are highly motivated to get the help you need to stop using drugs and alcohol? *

Yes

Would you prefer to live at home while you get outpatient treatment for addiction? *

Yes

I'm not sure

Do you have reliable access to the internet and a private space to go to for virtual meetings? *

Yes

Sometimes

How important is social interaction and forming connections with others to you? *

Very important

Somewhat important

Not important

Do you find it easier to share personal details in a virtual setting or in person? *

Virtual setting

In-person setting

I'm comfortable either way

Do you feel more motivated to attend sessions when you're physically at a treatment facility, or when you're able to join virtually from a location of your choice? *

Virtually

In-person

I'm motivated either way

Do you experience any physical or mental health challenges (such as mobility issues, anxiety, etc.) that make attending in-person sessions difficult? *

Yes

Yes, but they are manageable

How much do you appreciate the convenience of attending therapy from home, particularly if it helps you avoid distractions or triggering environments? *

Very much

Somewhat

Not Much

Not at all

Do you find it challenging to maintain focus or consistency during virtual recovery sessions? *

Yes

Somewhat

Not often

Would the flexibility of attending virtual treatment while balancing work, family, or other commitments be beneficial for you? *

Yes

Somewhat

Not really

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