Intake Review
Screen
Confidential Self-Assessment — For Your Safety
This brief screen helps determine whether this private service is the right fit for you. All responses are private and never shared. To proceed, you must answer “Yes” to all questions.
*** All information shared in this form remains strictly confidential and is not stored in any public or medical system. ***
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Questions? Please email: info@beataddictionnow.com
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Please confirm the following: (* All questions require an answer.)
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1) I am NOT currently in medical or psychological crisis (e.g., I am not suicidal, at risk of overdose, or experiencing hallucinations).
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2) I do NOT use any other substances (legal or illegal) daily or occasionally, other than the opiate(s) I plan to taper.
3) I have NEVER experienced seizures, hallucinations, or loss of consciousness during withdrawal.
4) I am NOT currently required by any court, employer, or government agency to attend treatment or submit proof of rehabilitation.
​​5) I am 21 years of age or older.
​​6) I understand that if I purposely misrepresent myself or provide false information on this form, I may be denied peer support and forfeit any payments..
Note: If you are 20 years old or younger, even if you are legally an adult, please speak with a trusted adult — such as a school counsellor, family member, or doctor — before seeking private peer support. It’s important to have guidance from someone closer to your situation.
All data saved on our server is encrypted.
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