Outreach & Support Intake Questionnaire

Thank you for reaching out. This questionnaire helps our team understand your situation, assess how we can best support you, and ensure alignment with our mission.

All responses are reviewed with care and confidentiality.

What is your name and contact information?

What led you to reach out to Every 11 Minutes at this point in your life?

Is this outreach for yourself or for someone you care about? Please explain your relationship.

Have you or the person you’re reaching out about received substance use treatment before? If so, how many times and what type of treatment?

What substances are currently involved, and how long has this been an issue?

Are you or the person involved currently working, in school, or neither? How stable does that situation feel right now?

Is there a family history of substance use, trauma, abuse, incarceration, overdose, or death that feels relevant to share?

What kind of support are you hoping for from Every 11 Minutes right now?

Are there any immediate risks or hardships you are dealing with (housing, medical, legal, safety, mental health, relapse risk, etc.)?

What are you realistically able to handle financially right now, if anything, when it comes to support, treatment, or resources? (There is no right or wrong answer—this helps us understand your situation.)

What is the biggest financial or personal hardship you are facing at the moment that makes this situation harder?