Intake Questionnaire

To have a FREE 30-minute consultation with Candace and her team, fill out and submit our Questionnaire.

Please fill the form in completely, as all fields are mandatory. Briefly give your heartfelt and honest answers below. (This site is secure and your answers are kept confidential.)

"*" indicates required fields

Name*

First Last

Phone*

Email*

Address*

Country

Time Zone*

Please let us know who referred you, if that's the case, so we know who to thank.*

Why is it important that you speak with us now?*

Have you received counseling for this issue before, and if so, what was your experience with that?*

Aside from counseling, what approaches have you tried in order to remedy this issue, and what kind of success did you find from those?*

Check each statement that applies to you full-heartedly:*

I am ready to take action to resolve this.

I am able and willing to follow through on counseling sessions and to implement suggestions I receive.

I am ready to look at how I have been contributing to the progression of this situation in my life.

I am willing to hold others accountable for their behaviors.

I am willing to financially participate in the successful resolution of this issue.

I see having an expert, specialized counselor as critical to my success.

I am open to exploring new ways of behaving with my addicted loved one and with other family members.

If you could work together with Candace and her team and resolve this issue once and for all, what kind of commitment to counseling can you see yourself making?*

What is the ideal outcome you’re looking for, regarding this issue?*

Before we start working together, is there anything else you think we should know?*

If you're in North America, please select your preferred contact method below.*

Phone

Email

How did you hear about Candace and the specialized, transformational work she does with the loved ones of people who have been struggling with addiction? Check any that apply.*

Google Search

Candace's Website

Candace's Books

Facebook

Twitter

YouTube

Instagram

Medium

Therapist/Counsellor/Doctor

BCACC

Counselling B.C.

Psychology Today