Private Counseling for Addictive Behavior Change Private Counseling for Addictive Behavior Change Warning: Please avoid using your Back Button while in this form, use the buttons below. If you desire private counseling to learn to modify unwanted habits and manage your "addictive" behavior, please fill out the following confidential questionnaire. I believe that it is completely unnecessary for you to label yourself as an "addict" or "alcoholic" in order to accomplish the changes that you desire! The below questions will help us save time. Filling this out will give me a sense of the behavioral challenges you wish to manage as I help you learn to accomplish—"better living through behavior change!" Your contact info is Required so that I can respond to your call for help! (Use an alias if you wish to hide your identity) Step 1 of 3 33% Disclaimer* I've read the 'Confidentiality Disclaimer' on the right. Name First Last Email PhoneAll questions below are optional! Just provide as much information as you wish. You may leave any of the below questions blank. Remember, you may wish to reserve for later your most guarded secrets. You can assure your utmost confidentiality by saving some information for our personal-private counseling sessions!Please summarize which drugs are being used and the amounts and frequency of use if you can.If you are struggling with behavior problems (gambling, pornography, shopping, compulsive computer use), please summarize your concerns below. Please summarize the negative consequences that you have experienced as a result of your history of drug use or addictive-compulsive behavior.How have you attempted to solve this problem on your own?If you have undergone formal addiction treatment or “rehab”, please summarize you treatment history.If you have sought nonprofessional help, please summarize your involvement with 12-Step programs like Alcoholics Annonymous, SMART Recovery and the like. How have these programs worked for you? Please Check Any of the below difficulties that apply to your current situation. Marital Problems Sexual Problems Financial Problems Black Outs Social Problems Passing Out Medical Problems Personality Changes Occupational Problems Depression or Anxiety Relationship Problems Shame and Embarrassment Legal Problems Children Negatively Impacted Please summarize related stressors, crises or personal challenges that you are currently experiencing.Describe other high-risk behaviors that are of concern to you.What do you what to see happen as a result of your counseling with me?What do you predict will happen if you don't learn to resolve your current challenges?