Name *

First Name

Last Name

Phone

(###)

###

####

1. When you drink alcohol, what is your main motivation? *

A. To relax or take the edge off after a long day.

B. To connect socially or enhance an occasion.

C. To escape or feel less overwhelmed.

D. I no longer drink, or I know I can’t drink safely.

2. How do you typically feel the day after drinking? *

A. A little groggy, but generally okay.

B. Normal—I'm used to it and don’t notice much difference.

C. Anxious, foggy, regretful, or depleted.

D. Grateful that I didn’t drink, or upset if I relapsed.

3. How easily can you go a week without drinking? *

A. Pretty easily, but I usually return to it.

B. I don't think about it unless I'm in social settings.

C. It feels difficult emotionally or mentally.

D. I avoid alcohol completely for my well-being.

4. Who are you without alcohol? *

A. More energized, clear, and connected to my purpose.

B. About the same—I feel neutral.

C. I don’t know. It’s been a long time.

D. Stronger, more grounded, and living in alignment.

5. What does alcohol cost you energetically or spiritually? *

A. A bit of clarity or motivation, but I manage.

B. I’ve never thought about it that way.

C. My peace, intuition, and sense of direction.

D. Too much. It derails my healing or puts me at risk.