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.