The following questionnaire encompasses many aspects of your life, and the life of your loved one. Please complete the items listed as applicable to the patient’s use of alcohol, drugs and/or other substances. Your comments will help us gain a comprehensive understanding of the patient’s circumstances as we develop his/her treatment goals.
Although some questions may seem obvious, please keep in mind the individual may/may not be aware of his/her behavior and how it has impacted your life. Please be specific and answer every item, providing examples if possible. The following information will remain confidential for the family work done with the primary counselor.