Family Questionnaire Form

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Family Questionnaire Form

Step 1 of 5 - Family Questionnaire

20%

Name of Client*
Relationship of Writer to Client:
Referred by:
Name of Writer:
Client
Client Name:
Age:
Client's Gender Assignment at Birth:
- Male
- Female
Clients Current Gender Identification:
- Male
- Female
- Non-Binary
Clients Sexual Orientation:
- Heterosexual
- Homosexual
- Bisexual
- Questioning
- Unknown
Current Address:
Home #:
Work #:
Email:*
Occupation:
Marital Status:
- Single
- Married
- Divorced
- Widowed
Family
Parents Name:
Second Parents Name:
Siblings and age:
Marital Status of Clients Parents:
- Married
- Divorced
- Separated
Mothers Contact Information
Current Address:
Home #:
Work #:
Cell #:
Email:
Occupation:
Fathers Contact Information
Current Address:
Home #:
Work #:
Cell #:
Email:
Occupation:
Physical Health
Current Health Conditions:
Significant Past Medical Conditions/Surgeries including year:
Please list all prescribed medications and doses that client is taking:
Has the client ever suffered from significant head trauma? If yes, please describe and include date:
If yes, did client get a head CT or MRI done?
- Yes
- No
IF YES, please list testing physican name and contact information, and if available forward testing results to PACE Recovery Center
Mental Health
Previous Diagnosis client has received:
History of Suicide Attempts:
- YES
- NO
If yes, please describe with dates:
History of Self Harm (cutting/scratching/picking):
History of Disordered Eating: (circle any)
- Over-eating
- Restricting
- Bulimia
- Anorexia
- Other
Is the client currently engaging in the disordered eating pattern to your knowledge:
- Yes
- No
When did you first notice this Disordered Eating:
What cross-addictive behavior have you noticed in client?
- Sex
- Gambling
- Social Media
- Video Games
- Relationships
- Eating
- Pornography
- Compulsive Spending
Have you identified anxiety or depression in client prior to his addiction issues, or when he has had a substantial period of sobriety 30 days or longer:
Trauma:
Please circle any that apply to client
- Sexual abuse
- Physical Abuse
- Verbal Abuse
- Death of Close Relative/Friend
- Medical Trauma
- Domestic Violence
- Witness of Violence
- Accident/Injury
- Natural Disasters
Has the client been in treatment before?
- Yes
- No
List names and dates of Inpatient/outpatient/detox treatment experiences:
If previous treatment was not successful, describe why you think it did not yield better results?
(ex: lived alone, in apartment with a roommate)
What recent crisis led you or the client to seek professional help? (Please be specific)

Description of the Problem
Answer questions to the best of your knowledge. Please do not leave blanks. Where appropriate, write “unknown”.
Client’s drug(s) of choice?
For how long has the substance use problem existed?
When and how did you first become aware of the problem?
Please check off symptoms and consequences associated with client’s substance abuse problem.
Please clarify frequency, duration, with whom etc.
- Personality Changes
- Extreme & Rapid mood swings
- Temper outbursts
- Extreme irritability
- “Blackouts” (memory loss)
- Fits of anger & rage
- Defensive & Argumentative
- Secretive & socially withdrawn
- Lying and deceitful
- Physically abusive
- Verbally abusive
- Sexually abusive
- Totally self-centered
- Irrational & out-of-control behavior
- health problems
- Neglect of household chores
- Neglect of work responsibilities
- Legal problems
- Loss of job, income
- Loss of personal property
- Isolation from family, friends, etc.
- Other

Patient’s Developmental History Before Age 18
Birth Complications:
Adopted?
- Yes
- No
Age at adoption
If adopted, was he adopted from another country?
- Yes
- No
Has he ever sought birth parents?
- Yes
- No
If yes, elaborate please
List Name and age of siblings, specify if they are step siblings or adopted
Educational Milestones (please describe academic performance)
How would you describe the clients experience with school academically?
How would you describe the clients experience with school socially?
Did the client experience any learning difficulties?
Has the client ever had academic testing? Please include the Provider Name, Contact Information, and Date these were done) IF you have copies of this testing please forward these to the Pace Clinical Team by either email or mail.
Highest Level of Education:
Employment dates / location:
Debt / Money Management Issues:
Client’s current / past hobbies:
Describe client’s dating history (long or short-term relationships, volatile / chaotic versus healthy, one versus many, ect.):

Family Dynamics
Please describe the relationship each family member has with client: Mother:
Father:
Siblings:
Other: (aunts, uncles, friends...)
Check all that apply
- beg & plead
- fight & argue
- “silent” treatment
- keep track of his whereabouts
- supply cash / credit cards
- pay other living expenses
- threaten users / dealers
- wakeup calls
- bail out of legal trouble
- taken over responsibilities for the client
- go on search missions
- play therapist trying to explain the problem
- play “if you really loved me, you would stop” routine
- play “if you don’t stop, I’ll get sick and die” routine
- hide or discard drugs / alcohol / paraphernalia
- call police / obtain order of protection
- throw him out of the house
- cut off all financial assistance
- completely stop trying to help
- call clinics / hospitals / doctors for help
- other
Describe the emotional impact of the client’s disease on the family:
Describe the financial impact of client's disease on the family:
Have you ever attended:
If yes, when, for how long?
Current frequency
Have you ever attended a family workshop or family support group during the client’s previous treatment?
- Yes
- No
if yes, explain:
What questions do you still have surrounding addiction?
What feelings does the client’s substance abuse set off in you?
- Anger
- Rage
- Sorrow
- Hopelessness
- Self blame
- indifference
- frustration
- shame
- helplessness
- resentment
- humiliation
- guilt
- revenge
- compassion
- confusion
- disgust
- inadequacy
- embarrassment
- contempt
- disappointment
- protectiveness
- inferiority
- Other
How will you respond, if the client continues or returns to using drugs / alcohol?

Needs, Limits & Preferences
What needs do YOU or other members of the clients FAMILY have including psychiatric, addiction, educational and or community involvement and how might we help you? (i.e information, therapy, emotional support, aftercare planning etc)
Is the client allowed to return home without completion of the agreed upon 90 days at PACE? If no, how will you maintain this boundary?
How long do you expect the client to remain in treatment before they are allowed to visit and/or return home?
Who in your family would you name as enabling the clients addictive behavior? Why and how does this person enable the client?
Phone
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