Internet Addiction Recovery Program APPLICATION ... - HEAL

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Internet Addiction Recovery Program WELCOME The reSTART Internet Addiction Recovery Program is specifically oriented towards launching tech dependent youth and adults back into the real world. Our individually tailored program is designed to assist participants with an internet and/or computer based behavioral addiction to break the cycle of dependency. Our 45‐day individualized abstinence based recovery program exposes participants to a variety of activities and everyday life skills which are often avoided or underdeveloped as a result of ongoing computer, video game play and internet abuse. Meet the Program Founders Hilarie Cash, Ph.D., Executive Director reSTART Internet Addiction Recovery Program Co‐founder of Internet/Computer Addiction Services and codeveloper of the Gaming and Internet Treatment Program. Hilarie is a speaker, teacher, and author and has appeared, among other places, on ABC News, CNN, NPR, PBS, the BBC, and in print in the Seattle Times, U.S.A. Today, U.S. News and World Report, and the New York Times. She has been in private practice for 25 years. Cosette Dawna Rae, MSW, Executive Director reSTART Internet Addiction Recovery Program Cosette is a psychotherapist, personal life coach, and stress management therapist specializing in the treatment of stress, anxiety, trauma and addictions. As a former IT professional with 20+ years experience in computer/internet technology, she understands the intricate nature of tech addiction and the tools necessary to bring about desired change. Cosette is a graduate of the University of Washington and Founder of Heavensfield Retreat Center. Page | 2 reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 restart@netaddictionrecovery.com | www.netaddictionrecovery.com
Internet Addiction Recovery Program PARTICIPANT DATA Participant ID ____________________________ Date ________________________ Counselor Assigned ________________________________ Referred by Self Clergy Friend Family Healthcare provider Other ________________ Phone __________________________ Participant Name ______________________________ MI _______ Last Name ______________________ Maiden ____________________ Student Address _____________________________________________________________________________________________________________ City ____________________________ State ________ Zip _________ Is student living at this address Yes No Cell Phone __________________________ Message Phone ____________________________________ Email __________________________________ Age _________ Date Of Birth ____________________________ Adopted Yes No Gender Male Female Height ____________________ Weight _________________ Shirt size __________________ Pant Size ________________ Shoe Size ______________ Ethnicity Asian/Pacific Islander White American Indian Hispanic African American Black International Student Religious Preference Christian Catholic Jewish Protestant LDS None, but I believe in God Atheist Other _____________ Parent Relationship Status Single Engaged Married Separated Divorced Widowed Father’s Name __________________________ MI ________ Last Name ______________________ Maiden ________________ Address __________________________________________________________________________________________________________________ City _____________________________ State __________ Zip _________ Is student living at this address Yes No Home Phone ________________________ Cell Phone ______________________Email Address ________________________________________ Employer__________________________________________________________________Work Phone ___________________________________ Mother’s Name __________________________ MI ________ Last Name ____________________________ Maiden ________________ Address __________________________________________________________________________________________________________________ City _____________________________ State __________ Zip _________ Is student living at this address Yes No Home Phone ________________________ Cell Phone ______________________Email Address ________________________________________ Employer__________________________________________________________________Work Phone ____________________________________ Step Mother’s Name _________________________ Home Phone _______________ Cell phone _______________ Email ______________________ Step Father’s Name _________________________ Home Phone _______________ Cell phone _______________ Email ______________________ Emergency Contact Information: Contact Name ______________________________ Home Phone ________________ Cell phone ______________ Email _______________________ Contact Name ______________________________ Home Phone ________________ Cell phone ______________ Email _______________________ Page | 3 reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 restart@netaddictionrecovery.com | www.netaddictionrecovery.com
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Internet Addiction Recovery Program APPLICATION ... - HEAL

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