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Intake Screening

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. ***

Questions? Please email: info@beataddictionnow.com

Please confirm the following: (* All questions require an answer.)

1) I am NOT currently in medical or psychological crisis (e.g., I am not suicidal, at risk of overdose, or experiencing hallucinations). *

Yes

2) I do NOT use any other substances (legal or illegal) daily or occasionally, other than the opiate(s) I plan to taper. *

Yes

3) I have NEVER experienced seizures, hallucinations, or loss of consciousness during withdrawal. *

Yes

4) I am NOT currently required by any court, employer, or government agency to attend treatment or submit proof of rehabilitation. *

Yes

5) I am 21 years of age or older. *

Yes

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.

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.. *

Yes

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Error, check all required (*) fields have been filled and try submitting again.

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

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