Family Questionnaire Print

FAMILY QUESTIONNAIRE / ASSESSMENT
The following questionnaire encompasses many aspects of the lives of the alcoholic/addict as well as their
family. Please check and comment on the items listed below as applicable to the individual’s use of
alcohol/drugs and/or other mood altering chemicals.
Your comments on these questions will help us gain a more complete understanding of the individual’s
problem.
Even though some of the questions may seem obvious, it is important to keep in mind the individual may
not be aware of his or her own past behavior.
Please be specific and answer every item, giving examples wherever possible.
The following information will be kept confidential and used by the treatment team.
Individual / Patient’s Name:
Your Name: ______ Your age:
Your Phone #: Home ( ) Cell (_____) Work: ( )
Your e-mail address:
What is your relationship to the individual? Spouse Significant Other Child Mother
Father Sibling Friend Other:
How many years have you been in this relationship? _____
How would you describe your relationship with the individual before and after his / her chemical use?
Please explain:
________________________________________________________________________________________
Are you living with the individual at the present time? Yes No
If yes, do you plan to continue living with the individual? Yes No
Have you given the individual an ultimatum? Yes No
If yes, how many times? _____________ Explain:_____________________________________________
If you are married to the individual, how many times have you been married?
How many times have you and the individual been separated or lived apart?
Do you and the individual have children? Yes No ___________________________________________
Are there any children from previous relationships? Yes No ___________________________________

Please list the names and ages of the children:
Name Age Living at Home
Yes No
Yes No
Yes No
Yes No
Do any of the children seem to have personality or emotional problems? Yes No
Of what nature:
Do any of the children seem to have difficulties or problems in school? Yes No
Explain:
Is any family member, besides the individual, presently seeking professional help for emotional or behavior
problems Yes No
If yes, please identify them:
Do any family members other than the individual, drink or use drugs? Yes No
If yes, please identify family members:
What drugs are you aware the individual has used or is using: Alcohol Marijuana Tranquilizers
Sleeping pills Pain pills Methamphetamine/Speed/Crystal Cocaine/Crack
Heroin Methadone Hallucinogens
Other:
Comment:_______________________________________________________________________
What is the individual’s drug of choice?
How long have you been aware of the individual’s alcohol/drugs use?
Has the individual had previous treatment for chemical dependency/addiction? Yes No
How many times? Where? When?
Length of stay? How long was he/she sober?

FAMILY QUESTIONNAIRE/ASSESSMENT
PAGE TWO
Has the individual expressed feelings of remorse, guilt, depression, anger/rage or suicide? Yes No
Explain:
________________________________________________________________________________________
_____________________________________________________________________________________
Has the individual’s drinking and/or drug use interfered with social relationships? Yes No
Explain:
Has the individual’s drinking and/or drug use interfered with his/her employment? Yes No
Unemployed Cannot hold a job Terminated Employer mandated treatment Suspended
Explain: _______________________________________________________________________________
Are you aware of any legal issues due to individual’s alcohol/drug use? Yes No
What are they?
The individual’s chemical use has affected YOU! My job My health Our relationship
Explain:
________________________________________________________________________________________
What steps have you taken to deal with the individual’s chemical use?
I have sought help from a doctor, therapist, clergy, psychiatrist, etc.
I have discussed the problem with family members.
I have attended or I am attending Al-Anon or other 12-step programs.
I have left or threatened to leave.
Other:
____________________________________
Has the individual engaged in acts of physical violence or verbal threats?

Yes No
Explain:
______________________________
What is your view of yourself?
I suffer from fears and anxieties about the individual a lot of the time.
I rarely feel angry, hostile, or resentful toward the individual.
I feel that the individual loves me deeply.
My use of alcohol is best characterized as:

I never drink.
I rarely drink or drink only socially.
Sometimes I drink to relax.
I drink two or more drinks a day.
Drinking is a problem for me.
I have used, or am using:

Marijuana
Tranquilizers
Methamphetamines
Pain medications
Other:
Has your chemical use increased to keep up with the individual or to deal with the outcome of the individual’s
drug/alcohol use? Yes No
What are you expectations regarding the individual’s disease and recovery?
Specific issues I feel I am dealing with include:

Denial
Minimizing
Anger/Resentment
Dependency in relationship
Individual’s resistance to recovery
Other (be specific):
Please Explain:
________________________________________________________________________________________
________________________________________________________________________________________
Have you ever attended Al-Anon? Yes No
Comment: ____________________________________________________________________________
FAMILY QUESTIONNAIRE/ASSESSMENT
PAGE THREE
Is there a person, or persons, you have concerns about visiting the individual while in treatment? Yes No
If so, please provide the name(s):
If the individual should choose to leave against staff advise:
Who would you want contacted?
1. Name: _________________________________ Relationship: __________________________________
Home Phone: ______________________Cell Phone: __________________Work:___________________
2. Name ___________________________________ Relationship:__________________________________
Home Phone: _______________________ Cell Phone: _________________ Work:____________________
We welcome any suggestions, concerns, or questions you have:
Please Check our Website for information on:

• Family Group meetings and times
• Frequently asked questions
• What to bring and not bring guide.
• Where to mail packages
• Articles about Addiction
• Co-Dependency Guide Book ( aka Nora’s Book)

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FAMILY QUESTIONNAIRE / ASSESSMENT

Individual / Patient’s Name:

Your Name: ______ Your age:

Your Phone #: Home ( ) Cell (_____) Work: ( )

Your e-mail address:

Father Sibling Friend Other:

How many years have you been in this relationship? _____

If yes, do you plan to continue living with the individual? Yes No

Have you given the individual an ultimatum? Yes No

If yes, how many times? _____________ Explain:_____________________________________________

Do you and the individual have children? Yes No ___________________________________________

Are there any children from previous relationships? Yes No ___________________________________

Name Age Living at Home

Do any of the children seem to have personality or emotional problems? Yes No

Do any of the children seem to have difficulties or problems in school? Yes No

If yes, please identify them:

What is the individual’s drug of choice?

How many times? Where? When?

Length of stay? How long was he/she sober?

Unemployed Cannot hold a job Terminated Employer mandated treatment Suspended

What are they?

Has the individual engaged in acts of physical violence or verbal threats?

My use of alcohol is best characterized as:

I have used, or am using:

Specific issues I feel I am dealing with include:

Have you ever attended Al-Anon? Yes No

If so, please provide the name(s):

If the individual should choose to leave against staff advise:

Who would you want contacted?

1. Name: _________________________________ Relationship: __________________________________

Home Phone: ______________________Cell Phone: __________________Work:___________________

2. Name ___________________________________ Relationship:__________________________________

Home Phone: _______________________ Cell Phone: _________________ Work:____________________

We welcome any suggestions, concerns, or questions you have:

Please Check our Website for information on:

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If yes, how many times? _ Explain:_________________________________

1. Name: _ Relationship: __

Home Phone: __Cell Phone: Work:_

2. Name _ Relationship:

Home Phone: _______________ Cell Phone: _ Work:____________