Concerned Person’s Form Below is a form for significant others to complete in an effort to provide a forum for you to be able to share how your loved one’s addiction has impacted you. We use the information to address how your loved one’s addiction manifests in their life, and helps us design a recovery management plan for them moving forward. When completing this form, strong emotions can surface. We encourage you to share this form with their small group of trusted peers. If you prefer this information to be kept confidential, please let us know. Concerned Person’s Form Please describe your relationship: What is the best time and the best number to reach you at? What is the best time for you to be contacted by the family program counsellor? Are process addictions an issue? Please describe. (shopping, sex, gambling, internet, work) Why did they decide to seek treatment at this time? What mood-altering chemicals do they currently/previously use? What is their awareness of the problem? No awareness: “I don’t have a problem. It’s not worse than anybody else’s.” Minimal awareness: “Sure, I’ve had a problem, but I can take it or leave it.” Moderate awareness: “I have a problem, but I can handle it on my own.” Admits to a problem and accepts responsibility for change. Have they ever made efforts to stop or cut down? How do they obtain money to buy alcohol or other drugs (or to engage in their process addiction)? Has this ever put a strain on family resources? Have they missed any family functions or stopped attending? Have family functions been affected by their addiction? Have any social functions been negatively impacted by their substance use? Have they ever been unable to remember what was done or said while under the influence of substances or while engaged in any addictive behaviors (blackouts)? Has their work ever been affected? If so, how specifically? Have they ever experienced legal problems associated with their addiction? Have they ever become aggressive or abusive as a result of their addiction? Please describe a specific incident(s). What are their behaviors that you disapprove of the most? Has their health been adversely affected by their addiction? If so, how specifically? What do you see as their strengths? Are there any issues that you think could affect their ability to get the most out of their treatment experience or on-going recovery experience once they transition out of Aurora? What are your hopes for them? What are your hopes for your relationship moving forward? What fears, if any, do you have once they transitions out of Aurora? Are there any additional resources you would like to see them participate in once they leave Aurora (i.e. on-going counselling, financial counselling, supportive living/recovery house, vocational training, legal support, relationship counselling)? Are you able to provide any additional details on how you have been impacted by their substance abuse? What has it been like for you? Information sharing – choose one: I would like to keep this information confidential. I would like to share this information with my loved one.
