General and Contact Information:
Your Relation to the Alcoholic/Addict:
City and State in which they live:
Can they travel outside of this area for
How old is the addict ?
Current drug (s) their using:
Substance Abuse History:
At what age did the individual start using the
Different drugs used:
Method of use:
Past treatment attempts (What rehab, when,
Does anyone in the alcoholics/addicts immediate
(blood) family have/or had a substance abuse problem? yes no
Any losses (death) or departures
(divorce-separations) from the family
institution?Ethnic/cultural background: C). Social
Any children? yes no
who has parenting responsibilities?
Has the individual enjoyed any social activities
in the past? (if yes, specify)
Has there been a gradual shift to non-involvement
in those activities? (if yes,
Has the individuals peer structure changed?
yes no D). Legal
Does the individual have a valid drivers license?
Has the individual ever been arrested? (If so, for
Are any crimes actively being committed to
support, or as a result of the alcoholism or addiction?
Highest grade completed in grade school :
Vocational Tech? yes no
Any desire or plan of continued or future
Is this the individuals chosen occupation?
If no what is?
Has the individual ever been terminated as a
result of substance abuse? yes no G). Medical
Does the individual have any medical problems?
Is the individual currently taking any
If yes, please specify what and
length of use:H).
Psychological and Behavioral History:
Has the individual ever been diagnosed and treated
for any psychological or emotional problems? yes no
If yes, please specify what and when and
outpatient or inpatient;
Was the individual prescribed medication for any
psychological/emotional problem ? yes no
If yes, please list what
drugs where prescribed and length of
On a Scale of 1-10, with 10 representing extreme
urgency, and 1 representing information for later use. Please assign
a number to this request :
Additional Information or