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Self-Awareness Form

It’s important to be aware of how your loved one’s substance use disorder could be affecting you. But it’s not an easy challenge to face. Put aside an hour or more to fill out this form with honest answers. We’ll use this information to ensure we provide the best support for you and your needs. Thank you!

Please be advised that Ashley Addiction Treatment staff are mandated reporters of child abuse and neglect, past or present, and vulnerable adult abuse and neglect.   

"*" indicates required fields

Name*
Today's Date*
Patient Name*
How are you feeling about your loved one’s treatment journey?*
(Please check all that apply)
Are there people, groups, or activities that help you feel supported during this time?*
If no, please put N/A.
Would you find it helpful to learn more about resources, support groups, or strategies that could benefit both you and your loved one?*
Do you feel your personal choices and habits have influenced your ability to support your loved one’s recovery?*
Do you currently use alcohol or other substances in ways that might make it harder for you to be fully present when engaging in your day-to-day life?*
Have you ever had an experience where substance use affected your interactions with your loved one?*
If no, please put N/A.
Have you experienced any legal restrictions that could impact your involvement in your loved one’s recovery?*
If no, please put N/A.
Are there any specific topics or situations that might be challenging for you to discuss with your loved one?*
If no, please put N/A.
Are you open to learning new communication strategies that could strengthen your relationship with your loved one?*
If recommended, are you open to participating in family therapy or educational programs?*