Heal Us Zimbabwe

Name *

Email address *

What is your age?

What is your gender?

What is your current employment status?

Please select at least one option.

Employed

Unemployed

Student

Retired

What substances have you used?

Please select at least one option.

Alcohol

Cannabis

Prescription Drugs

Cocaine

Heroin

Methamphetamines

How long have you been using these substances?

Have you previously sought help for substance abuse?

If yes, what type of help did you seek?

Please select at least one option.

Counseling

Rehabilitation

Support Groups

Medical Treatment

What are your main goals for seeking help?

Additional questions or comments