Participant Name
Phone
Your Email
How did you find our site?---Word of MouthAlumniEducation ConsultantMental Health ProfessionalSearch EngineOther
If other, please specify
In what country do you reside?---United StatesCanadaMexicoUnited KingdomAustralia ---------------AlbaniaAlgeriaAmerican SamoaAngolaAnguillaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia HerzegovinaBotswanaBrazilBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsChadChileChinaColombiaCongoCook IslandsCosta RicaCroatiaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEstoniaEthiopiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreat BritainGreeceGrenadaGuadeloupeGuamGuatemalaGuineaGuinea BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIreland (Republic of)IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKosovoKosrae IslandKuwaitKyrgyzstanLaosLatviaLebanonLesothoLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMexicoMoldovaMongoliaMontserratMoroccoMozambiqueNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPonapePortugalPuerto RicoQatarReunionRomaniaRotaRussiaRwandaSaipanSaudi ArabiaSenegalSerbia and MontenegroSeychellesSingaporeSlovakiaSloveniaSolomon IslandsSouth AfricaSouth KoreaSpainSri LankaSt. BarthelemySt. CroixSt. EustatiusSt. JohnSt. Kitts and NevisSt. LuciaSt. MaartenSt. ThomasSt. Vincent and the GrenadinesSurinameSwazilandSwedenSwitzerlandSyriaTadjikistanTaiwanTanzaniaThailandTinianTogoTongaTortolaTrinidad and TobagoTrukTunisiaTurkeyTurkmenistanTurks and CaicosTuvaluUgandaUkraineUnion IslandUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Virgin IslandsUzbekistanVanuatuVenezuelaVietnamVirgin GordaWallis and FutunaWestern SamoaYapYemenZambiaZimbabwe
How urgent is your need to get help?---I must get help immediatelyI am looking for treatment within the next weekI am looking for treatment within the next monthI am just evaluating the options for treatment
What issues would you like to address while at Medicine Wheel?
Adults must be willing to commit to treatment... Is your adult willing to commit to treatment? Yes No
Are there any legal or court issues pending? Yes No
Do you or your guardian/sponsor have access to the resources needed to pay for treatment? Yes No
If you choose to come would you or your guardian/sponsor need to borrow funds? Yes No
