Who We Treat
Why Choose Us
NAD IV THERAPY
TVR Method of Wellness
On Site Medical Care
Nutrition for Recovery
What do you see as the alcohol and/or drug problem for the client?
Alcohol and Drugs
No Alcohol or Drug Problem
If you think the client has a problem with drugs, list which drugs
Pattern of alcohol or drug use:
Continuous (continual regular pattern of use)
Decreasing but more problems
Sporadic (on and off with no pattern)
Periodic (fairly regular pattern but not continual)
Length of alcohol/drug problem:
16 years or more
What behaviors have you noticed that could mean the client has an alcohol or drug problem? List 3-4 things you have noticed.
Do you believe that the client recognizes his/her problem?
Explain what you have noticed about his/her awareness.
Describe client’s attempt to stop alcohol/drug use:
Inpatient Medical Care
AA or NA
Inpatient Psychiatric Hospital
Outpatient Addiction Counseling
Outpatient Psychiatric Hospital
Please list places client has been in treatment:
What other problems do you think the client has? (check all that apply)
What kinds of problems have the client’s drinking and/or use of drugs caused for you?
What have you done to handle or cope with these problems?
Are there other members of the family who have problems with alcohol or drugs?
If Yes, who?
Do you drink or use drugs (including prescribed drugs)?
If Yes, how much do you drink or use drugs (including prescribed drugs)?
If you are a spouse/partner of, or living with the client, in a romantic relationship – what is your marriage/relationship like?
Have you ever sought addiction treatment for yourself?
If Yes, please explain briefly:
We want you to be a member of the treatment team. Are you available to attend a family session?
The person you are concerned about has a chronic illness, which means no cure. He/she will need to continue in ongoing treatment after their initial treatment. This could include a halfway house or outpatient counseling. We need you to support this. The person you are concerned about also will need to attend at least support meetings (12-step/recovery oriented) every week for a minimum of two years after intensive treatment. We encourage you to support this also.
How may we contact you? Days? Evening?
This field is for validation purposes and should be left unchanged.
Why Choose Us