Family Questionnaire About YouPerson Completing Form Relationship to Client Your Email May we send you occasional updates via email?(Required)YesNoAbout TreatmentClient Name(Required) Today's Date MM slash DD slash YYYY Why did the client decide to seek treatment at this time?What mood-altering substance does the client currently use? (Mark all that apply)(Required) Alcohol Methamphetamines Amphetamine Cocaine Marijuana Tranquilizers (Valium, Xanax, etc.) Pain Medications (Vicodin, Opana, Percocet, Oxycontin, Dilaudid, etc.) Heroin Fentanyl Hallucinogens Inhalants (Glue, paint, gas) Over-the-counter medications Estimated amount used per day(Required) Prescribed?YesNoWhat is the problem as you see it? (Mark all that apply)(Required) Alcohol Illegal/street drugs Prescription drugs Combination of alcohol and drugs Emotional problems Family problems What is the problem as the client sees it? (Mark all that apply)(Required) Alcohol Illegal/street drugs Prescription drugs Combination of alcohol and drugs Emotional problems Family problems How would you describe the client’s awareness of the problem?(Required) No awareness: “I don’t have a problem. It’s no worse than anyone else” Minimal awareness: “Sure I have a problem, but I can take it or leave it” Moderate awareness: “I have a problem but I can handle it on my own” Admits to a problem and accepts the responsibility for change How long has the problem been going on?(Required) 0-6 months 6 months to 1 year 1-2 years 2-5 years More than 5 years Specify the Number of YearsThe client’s longest period of abstinence that you are aware of?Measure of timeDays, Weeks, Months, or years?DaysWeeksMonthsYearsWhen the client was abstinent, what was the reason they stopped using?Symptoms and BehaviorsWhich of the following symptoms of dependence apply to the client? (Mark all that apply.) Blackouts (cannot remember what they did while drinking) Hides and protects their supply of alcohol They cannot stop once they start Makes excuses for using alcohol or drugs Has a physical problem due to use (tremors, nausea, headaches) Personality changes while using Other Describe any other symptoms:Which of the following behaviors has the client demonstrated? (Mark all that apply) Violent, aggressive, or abusive behavior Unreasonable resentments (holds grudges) Change in type of friends Poor work or school performance Unable to participate in family functions Unable to perform daily functions they used to do How does the client obtain money to buy alcohol or drugs?How much do you think the client spends on alcohol or drugs? Has this created a problem for you, your family, or the client?How has the substance use changed family activities?Has the client had any previous experience with A.A., N.A.? Client has no knowledge Knows how to use AA or NA Critical of AA/ NA No strong response If so, what did they think about it?Any other addiction peer support groups attended? (LifeRing, SMART, Women for Sobriety, Celebrate Recovery, etc.) Has the client had any previous treatment before? (Mark all that apply) Attended AA/NA a few times Regularly participated in A.A. or N.A Psychiatric treatment Outpatient treatment Residential treatment If you marked any of the above please give the approximate dates of the treatment(s)Are there any other problems related to the substance abuse? School problems Work problems Legal problems Financial problems Family problems Psychiatric problems Explain:Family HistoryHave you or your family members experienced any of the following? Health problems Schoolwork problems Legal problems Financial problems Difficulty expressing feelings Explain:Please note any history of Alcohol, Drug or Psychiatric problems in the client’s family history:Grandmother (Mother's Side)(Required) Alcohol Drug Psychiatric Don't Know Grandfather (Mother's Side)(Required) Alcohol Drug Psychiatric Don't Know Mother(Required) Alcohol Drug Psychiatric Don't Know Aunts / Uncles (Mother's Side)(Required) Alcohol Drug Psychiatric Don't Know Grandmother (Father's Side)(Required) Alcohol Drug Psychiatric Don't Know Grandfather (Father's Side)(Required) Alcohol Drug Psychiatric Don't Know Father(Required) Alcohol Drug Psychiatric Don't Know Aunts / Uncles (Father's Side)(Required) Alcohol Drug Psychiatric Don't Know History of Alcohol, Drug or Psychiatric problems in siblings: (Please include sex and age.)Is there any history of suicide in the family on either side?(Required)YesNoPlease Note Whom:Did you grow up with any of these problems in your own family of origin?(Required)YesNoWhat treatment or recovery support have you sought for your self? AA/NA Al-Anon/Alateen Counseling Psychiatric visits None Explain:Are there any issues related to culture, ethnicity, religion, disability, age, gender or sexual orientation of which the staff should be aware?(Required) Yes No Please explain issues related to culture, ethnicity, religion, disability, age, gender or sexual orientation:Is there anything you believe may interfere with successful treatment of this client?(Required) Yes No Please describe anything you believe may interfere with successful treatment:May we use this information with our client? If you feel that you can give us permission, check the following box. If you do not want any information from this form shared with the client, simply do not sign below. I give Mountain Vista Farm permission to disclose information from this questionnaire to my significant other in treatment if it may further their treatment and recovery.Is there anything else you would like to share?(Required) Yes No Please feel free to write further comments. Thank you! Δ
