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