• Family Questionnaire

  • The following questionnaire asks very specific and personal questions not only about the patient, but also you, the family member. Some may be uncomfortable, some you may choose not to answer, some you may want to discuss with one of the Family Counselors verses writing it out, and some may not apply whatsoever. Please understand that we are attempting to be as thorough as we possibly can in order to assimilate as much information regarding the patient and family system so that we can provide optimum care.

    Often we are asked “Why the focus on me, I am not the patient?” Origins’ Family Services operates from the clinical belief that: “The Patient is the Family”

    As treatment proceeds with your loved one, you will be more involved and more engaged in the treatment process and outcome. As you will learn and experience in the intensive Family Program, the patterns and dynamics that exist within the family system has been significantly influenced by addiction. These influences are sometimes subtle and sometimes glaring and hard for a family member that is living within the system to recognize. Many of the questions that follow will assist in beginning to provide some clarity to the origin and extent of these influences.

  • This first series of questions will focus on your loved one who is in treatment. Please keep this in mind as you answer.

  • Has your loved one received previous inpatient or outpatient treatment for addiction/chemical dependency or mental health conditions (therapist, hospital, treatment center, support group, etc.)?
  • To your knowledge, does anyone in the patient's biological family have a history of problem with:
    Rows
  • The second series of questions will focus on you specifically and the entire family system in general. Please keep this in mind as you answer.

  • Do you support your loved one receiving treatment?
  • Are you willing to be involved in an intervention to keep your loved one in treatment should he/she decide to leave against staff advice (ASA)?
  • Should be Empty: