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Mr/Ms/Mrs |
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Mrs |
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First Name* |
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Address |
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Last Name |
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City |
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Phone |
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Postal/Zip Code |
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Email* |
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Country |
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Current length of abstinence from addictive substances? |
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Any current or former psychiatric problem? |
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Are you currently taking any medication… if so for what condition? |
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Is Co-dependency, gambling or sexual addiction also an issue? |
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Have you attended other addictions programs? |
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Do you have any Spiritual practices that help you in any way?... if so, then how long have you practised these? |
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Yes
No
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If so, who? (please give name and company) |
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Are you inquiring for yourself or for a loved one? |
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Would you like someone to chat with you about the many benefits program offered? |
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Privacy statement
If you register for programs, sign up for catalogues, newsletters, purchase services or products, or otherwise deal directly with Inner Care Services, your contact information and a transaction history will be retained by Inner Care Services. We will use this information to send you Inner Care Services communications, such as catalogues and e-mails and inform you of upcoming retreats etc. Your information will be kept strictly confidential! |
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