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About
Conditions We Treat
APEX Approach
Patient Journeys
Learn

Addictions Survey

Addictions Survey

Addiction Survey

Step 1 of 20

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Welcome. This survey will highlight underlying causes of your symptoms. What is your greatest frustration that you are looking for help with?*

Enter the symptoms or conditions you are looking for information or help with?

Do you have challenges with attention or focus?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Do you struggle with turning off certain urges or desires?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Do you experience self-destructive behavior (physically, mentally, or emotionally)?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Are you experiencing or have you experienced any recent changes in attitude or personality?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Are you experiencing or have you experienced disinterest in life or work?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Do you feel you have a lack of motivation?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Do you ever lie to others about your behavior?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Do you have mood swings, depression, or anxiety?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Do you feel you have a decreased memory or any confusion?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Have you seen a negative shift in your habits or priorities?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Do you have a decreased fulfillment, enjoyment, or engagement with life?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Do you struggle to keep up with academic or work-related tasks?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Do you have emotional or physical pain that provokes you to seek relief?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Have you experienced a breakdown in the quality and health of your relationships?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Have there been recent changes in weight or other physical qualities?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Have you had trouble with law enforcement due to your choices?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Have you experienced financial hardship because of your behavior?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Are you willing to do the work necessary to overcome these challenges?*
- Never / No
- Rarely
- Sometimes
- Often
- Always / Yes

Please enter the following information
Your Name*
Your Email*
Your Phone*
Thank you for taking the first step towards education and healing. We help people find their path back to health everday. Our clinical staff will review your survey and contact you with the results. What is your preferred way?*
- Short call! 🙂
- Email me! 🙂

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828.708.5274
info@apexbraincenters.com
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600 Julian Ln. STE 650,
Arden, NC 28704

Our approach is one of functional neurology. Through the use of state-of-the-art brain mapping, objective neurological testing, intensive research-based brain training methods, and nutritional intervention, we are able to assess and train the brain to perform at peak condition.

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