1.Which of the following best describes you?

I want to stop drinkingI want to control my drinking

2.Do you match this profile shared by our most successful clients?

Business owner, CEO, doctor, entrepreneur, lawyer, investor (including retired professionals), executive, engineer, consultant, psychologist, contractor or other high achiever in your field.

YesNo

3.What steps have you taken to control your drinking?

AASelf WillRehabCutting down your daily/weekly intakeSeen a mental health specialist Worked with family members Other (please specify)

4.What is your first name so we know how to address you?

5.When did you last drink?

6.If you describe your ideal life in two sentences what would it look like?

*7.Part of our method requires having some "skin in the game." How do you feel about investing in yourself?

The reason we're asking this is because having a commitment to invest in yourself is an important part of achieving successful outcomes with our program.(Required.)

8.What is your phone number

9.What’s your email address?

The reason we're asking this is for correspondence purposes and to send you call details. Rest assured, your email address will be kept confidential.

10.What’s are the three main things that alcohol dependency is holding you back from?