PERSONAL INFORMATION:

Name
Address 1
Address 2
Home Phone
Work Phone
Date of Birth	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Social Security
Request Phone Consultation
Referral Source
Type(s) of Service

Reason For Contacting AIG:

Counseling /or Consultation (Yakima, WA or Surrounding Areas)
Drug / Alcohol Assessment (Washington State)
Intervention (Anywhere in the Nation)

Reason(s) for seeking one or all of the above services

What do you hope to accomplish by contacting AIG?

Other than an initial consultation by phone, all services provided by AIG are paid for by the contracting person /or client. All payments are to be made by credit card or money orders.

All of the information provided here is provided to AIG consulting staff on its internet site for the initial intervention as part of its initial intake website process. I affirm that all of the information provided here, is made by the signer of this form, and is true to the best of my knowledge.