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1
What's your name?
*
This field is required.
First Name
Last Name
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2
Which SeekHealing community do you want to join?
*
This field is required.
Buncombe County (Asheville and Candler)
Haywood County
Online Community
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3
What pronouns do you go by?
Male: he/his
Female: she/hers
Neutral: they/theirs
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4
What's your ethnic heritage?
Please check all that apply.
White
Black or African-American
Hispanic, Latino or Spanish
Asian or Asian Indian
American Indian or Alaska Native
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
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5
Please check all languages that you speak fluently:
English
Spanish
Russian
Mandarin
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6
Do you identify as LGBTQIA+?
Lesbian, Gay, Bisexual, Transgender, Queer, Intersexual, Asexual?
YES
NO
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7
What's your phone number?
We do most of our communication and connecting people over text/SMS.
Area Code
Phone Number
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8
What's your email address?
We'll send you monthly emails so that you can see the details of all the community and Listening Training events in one place.
example@example.com
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9
What's a good mailing address for you?
So that we can send you care packages, help you out whenever you get sick, or need a helping hand with something else.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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10
Which one of these best describes your housing circumstances right now?
Please check all that apply.
I have access to stable housing and my housing situation is unlikely to change in the next year unless I choose to change it.
My housing situation tends to change every 1-3months.
I can't afford the housing that I have and am not sure how long I'll be able to keep it.
I currently don't have housing.
There have been times in the past year where I have not had housing.
I depend on other people in my community or family to provide for my housing.
I depend on government funding to provide for my housing.
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11
Do you use Facebook, and if so, can we add you as a friend?
We have a private facebook group for the Asheville Community called "Seekers" that we'll invite you to.
YES
NO
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12
How do you prefer we contact you?
Text message
Phone-call
Email
Facebook Messenger
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13
What's your birthday?
So that we can help you celebrate!
-
Date
Year
Month
Day
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14
How did you find out about SeekHealing?
Word of mouth, or from a friend
From a therapist or case manager
Google search
Facebook
Read an article, heard an interview, or saw a presentation
Saw a flyer
Peer Living Room or RHA
Justice Resource Center (JRC)
JFK ADATC
Sunrise Community
12 Baskets
Sober living or halfway house
Harmonia
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15
What attracts you to SeekHealing?
How did you hear about the project? Why are you here, and what do you want to get out of being involved in this program & community?
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16
Do you consider yourself a seeker?
A seeker is simply someone who has made a commitment to healing: to constantly re-evaluating your relationship with behavior(s) that don't serve you. That may involve overcoming a chemical addiction, or it may not.
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17
Do you have a substance use history?
Note: it is not required that you answer "yes" in order to join the program. If you have dealt with other addictions not related to substance use, answer no here (we'll get that info from ya in a couple questions)
YES
NO
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18
If you do have a substance use history, what chemicals have you been bonded to, currently or in the past?
Alcohol
IV drug user
Heroin
Fentanyl
Pharmaceutical opioids (i.e., pain pills)
MAT opioids (i.e., methadone, buprenorphine/suboxone)
Cocaine
Crack cocaine
Meth
Pharmaceutical amphetamines (i.e., Adderall, Ritalin, Vyvanse)
Cannabis/marijuana
Kratom
Caffeine
Sugar
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19
What non-substance related addictions have you been bonded to, currently or in the past?
Social media
Netflix bingeing
Gambling
Sex
Work
Porn
Video games
Self-harm
Eating disorder(s)
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20
What are your CURRENT intentions for addiction healing?
Please check all that apply.
100% abstinence from all mind-altering substances
Abstinence from one or more substances, moderation with others
Use methadone, buprenorphine/suboxone, or kratom to taper down to abstinence from opioids
Use methadone, buprenorphine/suboxone, or kratom to maintain a safer opioid bond
100% abstinence from a particular behavioral addiction
Moderation with a particular behavioral addiction
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21
What are your other intentions for healing & personal growth?
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22
On a scale of 1-10, how would you rate your capacity for connection in your life?
1 -- There is no one in my life that I could talk with about things I’m ashamed of. My social anxiety makes it almost impossible to connect with new people
2
3
4
5
6
7
8
9
10 -- I have multiple people I can share anything with and feel capable of creating new authentic connections with strangers.
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23
How many people in your life do you trust enough to share absolutely anything with?
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24
How confident are you that you will be alive one year from now?
Improbable twists of fate aside.
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25
How confident are you that you will be alive AND thriving one year from now?
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26
What kinds of things help you feel more connected?
Talking to your best friend, yoga, running, twerking, meditating, listening to music, petting cute animals, climbing mountains, ceremonial medicine work, doing backflips ... what's your Connection Booster of choice? (and if you don't know yet, don't worry -- you're in the right place to find out :)
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27
Have you already had or scheduled a First Conversation meeting with someone on the SeekHealing team?
The First Conversation is a 1-on-1 meeting for us to connect with you in person in addition to this form, to give you the DL on how this whole thing works and help you access the SeekHealing community & programs in a way that best serves your needs.
YES
NO
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