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Abide Network Intake Form

Marital Status
Is your spouse willing to come for coaching?
How would you like to begin your journey towards improving your mental health?
Do any of the below situations describe yours?
Is the medication effective?
Are you adhering to the suggested medication use?
Are you dependent on any drugs or alcohol?
Do you smoke?
Did you ever experience any emotional/physical or sexual abuse as a child?
Have you ever made a suicide attempt?
How did you hear about Abide Network?
Are you flexible if that person isn’t available?
Do you prefer male, female, or either?

Thank you for filling out the intake form.
Our Intake Coordinator will contact you within a week.

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