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Addiction Questionnaire

Addiction Questionnaire

Addiction Questionnaire

For futher free information and advice relating to your specific problem please complete the simple questionnaire below. All enquiries are in the utmost confidence.

 
First Name *
Last Name
Town/City/Location *
Country (If not UK)
Email *
Telephone *
Mobile No.
 
Person you wish to receive help for?
 
If "Other", who are you concerned about?
Name 
Relationship 
 
Does the addict want help?
Drugs or alcohol being abused?
Available budget for treatment?
 
Best time to reach you 
Any other question / details 
 
* Required Fields