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Outpatient Self-Awareness Form

Substance use disorders affect the entire family. Participants in the Outpatient Program need to have a strong support system at home. But family members must also be aware of how their loved one’s SUD could be affecting them. Fill out this form with your honest answers and we’ll use this information to assist in our treatment and care/support of you and your loved one. Thank you!


  • Please answer as many questions as possible. You may bring this with you to the Family Wellness Program.

  • SELF ASSESSMENT

    Please answer these questions as they relate to YOU.

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Main Campus
800 Tydings Lane
Havre de Grace, MD 21078
(800) 799-4673

Bel Air Outpatient
802 Baltimore Pike
Bel Air, MD 21014
(866) 697-0674

Elkton Outpatient
Union Hospital Professional Building
111 W. High Street, Suite 109
Elkton, MD 21921
(866) 697-4402

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