Outpatient Self-Awareness Form

Address: 800 Tydings Lane, Havre de Grace, Maryland, 21078, US
Telephone: (800) 799-4673

Name
First Last
Email
Today's Date
Relationship to Patient
Patient Name
First Last
Your Age
Your Occupation
Please answer as many questions as possible. You may bring this with you to the Family Wellness Program.
Do you believe that your loved one has the disease of alcoholism/chemical addiction?
- Yes
- No
Do you believe that you can cure him/her?
- Yes
- No
Do you think you have been affected by his/her chemical addiction?
- Yes
- No
How do you think you have been affected by his/her chemical addiction?*
How often do you express your anger over the chemical use?
- Never
- Seldom
- Often
How do you express your anger?*
Has the patient’s drinking/drugging caused problems in family activities?
- Yes
- No
Has the patient been aggressive to you or others in the family?
- Yes
- No
At times, have you drunk/drugged with the patient?
- Yes
- No
Do you feel guilty about or responsible for his/her drinking/drugging?
- Yes
- No
If treatment is successful, do you believe he/she will be able to return to normal drinking?
- Yes
- No
Do you believe that if he/she really loved you, he/she wouldn’t drink/drug again?
- Yes
- No
Do you love the patient deeply?
- Yes
- No
Do you feel that he/she loves you deeply?
- Yes
- No
Are you thinking of giving up the relationship?
- Yes
- No
Have you ever thought that YOU may have a problem with alcohol/drugs?
- Yes
- No
Are you in recovery?
- Yes
- No
How often do you drink? How often do you use drugs?*
When was your last drink? When was your last drug? What was it?*
Are you supportive of the recommendation that patients attend 90 AA/NA Meetings in 90 days post discharge?
- Yes
- No
Are you supportive of the recommendation that patients return to an alcohol and drug free living environment?
- Yes
- No
Have you ever attended AA/NA? If “yes,” for what purpose? Was it for your family or yourself?
- Yes
- No
What purpose? Did it for your family or yourself?
Have you ever attended Al-Anon and/or Nar-Anon? If “yes,” describe your overall experience.
- Yes
- No
How was your overall experience?
Are you an adult child of an alcoholic or chemically addicted parent(s)? If “yes,” how has this impacted on your adult life?
- Yes
- No
How has this impacted on your adult life?
SELF ASSESSMENT
Please answer these questions as they relate to YOU.
Do you drink/drug to reduce nervousness?
- Yes
- No
Do you require a drink/drug the morning after heavy drinking/drugging?
- Yes
- No
Do you prefer to drink/drug alone?
- Yes
- No
Do you lose time from work due to drinking/drugging?
- Yes
- No
Does your drinking/drugging cause conflicts at home?
- Yes
- No
Does your drinking/drugging make you careless of your family’s welfare?
- Yes
- No
Do you crave a drink/drug at a definite time daily?
- Yes
- No
Has drinking/drugging made you irritable?
- Yes
- No
Has your chemical use changed your personality?
- Yes
- No
Do you have difficulty sleeping as a result of your drinking/drugging?
- Yes
- No
Has your use of chemicals made you more impulsive?
- Yes
- No
Has your initiative decreased since you began to drink/drug?
- Yes
- No
Has your ambition decreased since you began to drink/drug?
- Yes
- No
Are decisions easier to make after a few drinks/drugs?
- Yes
- No
Do you drink/drug to obtain social ease?
- Yes
- No
Do you feel more secure when you are drinking or using drugs?
- Yes
- No
Do you drink/drug to relieve feelings of inadequacy, fear or insecurity?
- Yes
- No
Has your jealousy increased since you started to drink/drug?
- Yes
- No
Have you become more moody since your drinking/drugging?
- Yes
- No
Has your efficiency decreased since you began your chemical use?
- Yes
- No
Are you harder to get along with since your drinking/drugging?
- Yes
- No
Do you turn to an inferior environment when you drink/drug?
- Yes
- No
Is your chemical use endangering your health?
- Yes
- No
Do you always drink more than two (2) drinks?
- Yes
- No
Do you ever suffer from self-disgust from your drinking/drugging?
- Yes
- No