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Intake Questionaire

Strictly Confidential – For Private Use Only
This information is never shared, reported, or stored in any public system. It is used only to determine if this private, non-medical support service is a safe and appropriate fit for you.

(*) All questions require an answer.

Section 1: Consent & Confidentiality

1) Do you understand that this service is private, peer-based, and not affiliated with any government, medical, or legal agency?
2) Do you agree not to expect medical care, prescriptions, detox, or crisis services as part of this support?

​ Section 2: Substance Use Overview (Private & Honest)

3) What type(s) of opiates do you currently use? Required
5) Do you use benzodiazepines (benzos) such as Xanax, Ativan, Clonazepam, or Valium?
6) What’s your primary reason for using opiates? Required
7) What’s your primary reason for using benzos (if applicable)? Required

Section 3: Patterns & Risks

8) Do you ever binge (take much more than usual in a short time)?
9) Have you ever experienced severe withdrawal symptoms?
10) Have you ever been hospitalized, treated, or arrested due to your substance use?

Section 4: Goals & Intent

11) What are your reasons for wanting to quit or reduce your use? Required
12) What have you tried before (if anything)? Required
13) Are you ready to start tapering or quitting within the next 30 days?

Section 5: Contact & Safety

14) Preferred contact method? Required
15) Are you currently safe and stable (housing, food, sleep)?
16) Is there anyone in your life (friend, family, etc.) who knows and supports your decision to quit?

All data saved on our server is encrypted.

Final Note:

This form is not part of any public or government system. It is strictly used for private peer support and will never be shared, reported, or stored in a medical database.

 

Your honesty helps ensure this process is safe and right for both of us.

Quit opiates quickly, privately, and confidentially.

Peer-supported recovery from opiate addiction using a proven fast-taper plan specifically structured for you.

ADAPT, SURVIVE, LIVE

Beat Addiction Now

© 2025 BeatAddictionNow.com by Gerald Kichok
Located in Vancouver, British Columbia, Canada

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I acknowledge and thank the  xʷməθkʷəy̓əm (Musqueam), Sḵwx̱wú7mesh (Squamish) and səlilwətaɬ (Tsleil-Waututh) Nations, on whose traditional, ancestral, and unceded territories I live and work. I am grateful to be able to support people and offer my services on this land.

released December 7, 2025​

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