• Your Details
      • 1) Please advise a first name so I can personalise my response to you.
        (This does not have to be your first name)
      • 2) Age
      • 3) Sex M/F
      • 4) Email
      • 5) Religion
        (How does this affect your drinking? Does it offer support?)
      • 6) Country of residence
      • 7) Current Work (occupation, full-time/ part time?)
      • 8) Please state and describe any medical conditions
      • 9) People you live with (state relationship/ ages)
        (How do they affect your drinking?)
      • -
      • 10) Physical Disabilities
        (Please state and explain if they affect your drinking)
      • 11) Significant history of mental health problems:
        (e.g. Periods in psychiatric hospital describe reason, length and frequency. Mental health diagnosis (please state))
      • 12) Medication
        (State medication name or type and what you take it for)
      • 13) Are you going through any stress, changes or difficulties at this time?
        (Please explain how this is affecting you.)
      • 14) Are there still any aspects of your childhood that still affect you in daily life?
        (Please explain how these affect you.)
      • 15) Have you or anyone close to you been affected by any of the following?
        (Please explain how this affects you?)

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