Washington DC & Arlington
Sober Coach & Companions
Your Contact Information
Are you inquiring for yourself or for another person?
Help for myself
Help for another person
If the Client will be someone else, what is your connection to the Client?
Preferred Phone Number
Alternate Phone Number
In what city do you require service?
Will travel be required during service?
Yes, travel will be required during service.
No, travel will not be required during service.
Not sure whether travel will be required.
Which service do you require?
24/7 Sober companion
Daily or Nightly Sober Coach
Sober Escort (travel to and from specific location for a specific time period)
Not sure which type of service will be needed
Is the Client currently in rehab?
Yes, Client is currently in rehab.
No, Client is not in rehab.
Has the Client been to rehab at least once?
Client has been in rehab at least once.
Client never has been to rehab.
Which drugs present problems for Client?
Where will Client live while we provide service?
Client will live alone.
Client will live with his/her family.
Client will live with roommate(s).
Children will be present in the home.
Client will be traveling (staying in hotels or with friends or family).
What days will you require service?
7 Days Per Week
Does the Client currently suffer from any of the following?
High Blood Pressure
Low Blood Pressure
I am unaware of any serious physical condition at this time.
Has Client been diagnosed with any of these conditions?
Borderline Personality Disorder
ADD or ADHD
Other disorder - not listed
There is no co-occurring mental disorder.
Current Medication Status:
Client is currently taking medication as prescribed.
Client is not taking medication as prescribed.
I don't know whether Client is taking medication as prescribed.
Please list any prescription medications Client is currently taking.
How would you describe Client's nutritional habits?
Please include any additional information you feel will be helpful prior to our telephone assessment.
How do you want to be contacted?
Contact me via phone.
Contact me via email.
Should be Empty:
IN THE PRESS
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