Family Questionnaire


The following questionnaire encompasses many aspects of your life, and the life of the alcoholic/addict. Please check and comment on the items listed below as applicable to the Client’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 Client’s circumstances. Even though some of the questions may seem obvious, it is important to keep in mind the individual may or may not be aware of his or her own past behavior or of how it has impacted your life.

Please be specific and answer every item, giving examples wherever possible.

The following information will be kept within the confines of Blueprints for Recovery and the family work done here.

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 a little more

Are you living with the individual at the present times?

Yes No 

If yes, do you plan to continue living with the individual?

Yes No 

Have you given the individual an ultimatum?

Yes No 

Did you mean it?

Yes No 

Has there been an intervention?

Yes No 

Were you able to set boundaries and keep them?

Yes No 

What do you understand about the disease of addiction?

Is there addiction in your family of origin? Explain.

Did you grow up in alcoholism, addiction, or untreated mental illness?

Yes No 

Explain:

Please list the names and ages of any children still 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 these family members using/abusing?

Alcohol Marijuana Tranquilizers Sleeping pills Pain pills Methamphetamine/Speed/Crystal Cocaine/Crack Heroin Methadone Hallucinogens Other 

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?

How much has the client's treatment cost you up to this point?

Has the individual expressed feeling of remorse, guild, depression, anger/rage or suicide?

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 individuals alcohol/drug use?

Yes No 

What are they?

How has the client's chemical use affected YOU! Job, Health, Relationships, and Overall Well-being

What steps have you taken to deal with the client's addiction?

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 thrown the client out or threatened to. 

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

Yes No 

Explain:

What is your view of yourself?

Do you carry guilt or take responsibility for the client's addiciton?

Yes No 

Do you drink?

Yes No 

Do you feel a need to drink?

Yes No 

Have you ever experienced an eating disorder (compulsively overeating, restricting, or bulimia?)

Yes No 

Has there been trauma in your own life?

Yes No 

Explain:

I notice that:

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 

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 your 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:

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?

We welcome any suggesstions, concerns, or questions you may have
Please check our website for information on

-Family Group meetings and times Ala-Non Family Groups, Al-a-teen, ACA
-Frequently Asked Questions
-What to bring and not to bring
-Where to mail packages
-Articles about addiction
-Co-Dependency (Melodie Beattie) Co-dependent No More, Beyond Co-dependency, Language of Letting Go

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 the outcome of the individual's drug/alcohol use?

Yes No 

What are your 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

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?

We welcome any suggesstions, concerns, or questions you may have.
Please check our website for information on:

-Family Group meetings and times Ala-Non Family Groups, Al-a-teen, ACA
-Frequently Asked Questions
-What to bring and not to bring
-Where to mail packages
-Articles about addiction
-Co-Dependency (Melodie Beattie) Co-dependent No More, Beyond Co-dependency, Language of Letting Go


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