Is someone you know suffering from an addiction?

If someone you know is suffering from an addiction, and you would like him or her to be considered for participation on Intervention, please fill out the form below. The information you provide will be submitted directly to the production team that produces Intervention for A&E Television Networks (AETN). Your information will not be seen by AETN unless presented to AETN by the production team. By submitting this information, you give the right to use the information below in connection with Intervention.

You acknowledge that you may not receive a response from this submission. IF YOU BELIEVE THAT THE SITUATION YOU DESCRIBE BELOW REQUIRES URGENT ATTENTION, PLEASE CONTACT AN APPROPRIATE CARE PROVIDER.

If you are chosen to participate you will be required to sign appropriate releases. Please remember that the person suffering from an addiction cannot know about the possible intervention or offer of treatment in order to insure the best chances for success.

	All fields are required unless otherwise noted.
	Your Name:
	Your Age:
	Email Address:
	Phone Number:
	Does the addict live at the number provided?	no yes
	Alternate Phone Number:
	Address 1:
	Address 2: (optional)
	City:
	State:
	Zip Code:
	Your Occupation:
	Name of the person with the addiction:
	His or her age:
	City and State he or she lives in:
	His or her relationship to you:
	How long have they been addicted?	years, months
	Type of addiction:
	What is his or her occupation?
	How many friends and family would participate in an intervention?
	Please briefly describe the situation with your loved one here:

	STORY SUBMISSION FORM This is a legal document affecting your rights and responsibilities: please read it carefully before signing
	I, agree to complete and submit this story submission form (the "Form") for the purpose of being considered to become a participant in the television show entitled "Intervention" (the "Program"). I am making the representations, disclosures, and agreements described below in this Form so that Producer will continue to consider me to become a participant in the Series. If any disclosure or representation is false, misleading or incomplete, or if I breach any agreement made in connection with the Series, Producer may remove me from further consideration as a participant.
	I agree that I have not made, nor will I ever make any false or misleading statements regarding the Program, my participation in the Program, or the person that I am submitting for appearance in the Program ("Subject"). I agree that I have not, nor will I engage in any deceptive or dishonest act with respect to the Program, including but not limited to informing the Subject about the intervention or offer of treatment, the intended outcome of the Program, or any confidential knowledge I have with respect to the Program.
	Please type in your NAME here which signifies that you are agreeing to the above terms of the Story Submission Form:
	Please check this box which signifies that you are agreeing to the above terms of the Story Submission Form.
	Confirmation Phone(same as phone above):
	Date: (mm/dd/yyyy)
	Person that is the subject of the story:
	Additional Materials Supplied (Do not exceed 60 characters. If none, please write NA.):