This is an application to the TV show Intervention on A+E.
Participants on the show can receive up to 90-days of treatment. If you have a loved one struggling and would like to apply please fill out the form below.
Your name:
*
First Name
Last Name
Birthdate
*
mm/dd/yyyy
Select your gender:
Please Select
Female
Male
Genderqueer/Non-Binary
Prefer Not To Disclose
Other
If Other Please Describe:
Your Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
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Louisiana
Maine
Maryland
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Michigan
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Pennsylvania
Rhode Island
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Tennessee
Texas
Utah
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Your email address:
*
Check the box to acknowledge your consent to receive email updates. (If your loved one has access to this email please do not check the box):
Send me email updates.
Does the person in need of help have access to the email address above?
Please Select
Yes
No
Your occupation:
Your mobile phone number:
*
-
Area Code
Phone Number
Can you receive text messages on your mobile phone:
Please Select
Yes
No
Who currently lives in the house with you?:
Does the person in need of help have access to your mobile phone?
Please Select
Yes
No
Your secondary phone number:
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Area Code
Phone Number
Does the person in need of help have access to your secondary phone?
Please Select
Yes
No
Name(s) of the person or people in need of help:
*
First & Last Names
Name of the person or people in need of help:
First Name
Last Name
Does the person or people in need of help have access to any of the phone numbers you have provided above? If yes, check all applicable boxes.
Mobile
Secondary
Age(s) of the person or people in need of help:
*
Gender(s) of the person or people in need of help:
*
Please Select
Female
Male
Genderqueer/Non-Binary
Prefer Not To Disclose
Other
Gender(s) of the person or people in need of help:
Female
Male
Genderqueer/Non-Binary
Prefer Not To Disclose
Other
If Other Please Describe:
City and State where person or people in need of help lives (please include address if available or let us know if they are homeless):
*
Race/Ethnicity of the person or people in need of help:
Occupation of the person or people in need of help:
Previous occupation of the person or people in need of help:
Your relationship to the person or people in need of help:
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Who is/are your loved one(s) currently living with?
*
Is your loved one currently in a relationship?
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If so, how would you describe their behavior together?
If they are in a relationship, what is the name of the person they are in a relationship with?
How long have they been in the relationship?
How much time do you spend with your loved one(s)? When is the last time you saw them?
Please include a link to any of your loved one's social media pages: (enter none if not available).
*
What is/are your loved one(s) addicted to?
How long do you believe your loved one(s) has been addicted?
What do you believe is the frequency of use (or compulsive behavior) per day?
How do/does your loved one(s) afford their addiction (to the best of your knowledge)?
Do you think the addiction/compulsive behavior has reached a level of crisis or desperation? If so, Why?
What do you believe caused the addiction or compulsive behavior?
Why isn’t/aren't your loved one(s) getting help on their own to overcome the addiction/compulsive behavior? Has/Have your loved one(s) received help before?
Have there been any mental illness/psychological diagnoses? (Anxiety, Depression, Bipolar, Schizophrenia, etc)
Describe the personality and potential of your loved one(s) before the addiction.
Describe the personality of your loved one(s) NOW.
What toll has dealing with an addicted loved one taken on the family? Please describe:
Strained relationships? Arguments? Financial hardships? Blaming? Raising their children? Something else?
Are you ready to stand up to your loved one(s) and support them by offering the help they need?
*
Please Select
Yes
No
If your loved one(s) can get help, are you willing to travel to their location for taping?
How many people would be willing to participate in an intervention?
How many people would be willing to participate in an intervention?
Please provide the names and locations of those who would be willing to participate in an intervention. (Ex: Jane Smith San Diego, CA, Joe Smith Charlotte, NC etc...)
What is your normal work schedule?
Should this move forward are you willing to take time off work to accommodate filming if needed?
Does the person or people in need of help have children?
*
Please Select
Yes
No
If the person/people in need of help does have children, what are their ages?
Also, if yes, who has legal custody (i.e., who are their legal guardians)?
Are they available to participate in the production?
Please list your loved one’s daily/weekly activities and the people with whom they spend the most time.
Please tell us anything else you think we should know. (350 word limit)
How did you find out about this website?
Facebook
Twitter
Television Program/Advertisement
A&E Website or A&E Facebook Page
Other
If Other Please Describe:
Name
*
First Name
Last Name
Date
*
Submit
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