Get Started | KCB RecoveryTell us about you About You Experiences Your History Preferences Get Started What is your Name? Enter your name: What is your Email Address? Enter your email address: What is your phone number? Enter your phone number What Country are you from? Enter your country: What is your gender?Select one of the options below: Male Female What is your age?Select one of the options below: 18 - 24 Years old 25 - 34 Years old 35 - 44 Years old 45 - 54 Years old 55 - 64 Years old 65 Years or older What is your Relationship Status?Select one of the options below: Single In a relationship Married Divorced Widowed Do you consider yourself to be religious?Select one of the options below: Yes No Over the past 2 weeks, have you been bothered by any of the following problems:Select the options below: Little interests or pleasure in doing things Moving or speaking so slowly that others have noticed Being fidgety and restless Feeling down, depressed or hopeless Trouble falling asleep Trouble staying asleep Sleeping too much Feeling tired or having little energy Overeating Poor apitite Feeling bad about yourself and feeling like you've let yourself down Feeling like you've let others down Trouble Concentrating on thingsHow difficult has these problems made it for you to get along with others or take care of thing at home or at work? Very difficult Somewhat difficult Not difficult When was the last time you thought about suicide? In the last 2 weeks Over a month ago Over 3 months ago Over a year ago Over 5 years ago Over 10 years ago Never Are you currently experiencing anxiety or panic attacks? Yes No Are you currently taking any medications? Yes No Are you currently experiencing any chronic pain? Yes No Have you every been in counselling or therapy for your drinking or Drug Use before?Select one of the options below: Yes No How would you rate your current Physical Health Good Fair Poor How would you rate your current Mental Health Good Fair Poor How would rate your current eating habits? Good Fair Poor How would you rate your current sleeping habits? Good Fair Poor Are you currently experiencing overwhelming sadness, grief, or depression? Yes No How often do you drink alcohol? Once Daily Multiple times per day At least once weekly Every other week Monthly Yearly I'm currently not drinking Never How often do you use drugs? Once Daily Multiple time per day At least once weekly Every other week Monthly Yearly I'm currently not using Never How often do you use smoke? Daily Multiple times per day At least once weekly Every other week Monthly Yearly I'm currently not smoking Never Do you have a preferences for your Coach?Select the option below: A coach that is Assertive and pushes me towards my goals A coach that is compassionate yet holds me accountable I have no specific preference What brings you here?What are you looking to achieve Abstinence Moderation More control over my habits Drinking/Using only on specific occasions I don't know yet Other Please specify (in a few sentences) a bit more about your situation and what you are looking to achieve. This will give your coach a good understanding of the best place to start and personalize your recovery. roadmap. How did you hear about KCB Recovery?Select an option below Youtube Google Search Facebook Podcast Social Media post Family or friends Another website Email Other SHOW SUMMARYSome required Fields are emptyPlease check the highlighted fields. Submit Previous Step Next Step Share this:Click to share on Facebook (Opens in new window)Click to share on X (Opens in new window)