Goal

/pre-intake questionnaire

Residential
pre-intake questionnaire

This form helps us get to know you better, understand your background, and determine if our residential program is right for you right now. It also enables us to make the intake interview more effective. You don't have to share all the details about your trauma here. You can indicate that you would rather not answer.

01 Basic information

02 Legal and practical status

03 Why now?

Please answer succinctly.

04 Substance Abuse and Compulsive Behavior

05 Previous treatments

06 Mental Health Signals

07 Safety check

Answer honestly — that helps us keep everyone safe.

08 Medical considerations

09 Relationships and support

10 Compliance with the Affect2U Residential Program

Our program is:

  • Group-oriented and relational

  • Trauma-informed

  • Emotionally focused

  • Requires shared responsibility, boundaries, and community living together

  • It's not just about quitting substance use, but also about inner change.

11 Willingness and dedication

12 Is there anything else we need to know before we meet?

Declaration

I confirm that the information provided is accurate to the best of my knowledge.

Thank you.
A team member will review your responses before your intake interview.
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