Name of person filling out this form
Relationship To Loved One
Name of loved one
Is your loved one currently a client at Alpine Recovery Lodge?
Yes
No
What are you most concerned about right now?
Alcohol use
Drug use
Prescription medication misuse
Mental health symptoms
Suicidal thoughts or behaviors
Anger or aggression
Trauma-related symptoms
Relapse risk
Daily functioning
Other
Which substances are you aware of?
Alcohol
Fentanyl
Heroin
Prescription opioids
Methamphetamine
Cocaine
Benzodiazepines
Marijuana
Kratom
MDMA/Ecstasy
Multiple substances
Unsure
Other
How long has this been going on?
How often is your loved one using right now?
Daily
Several times a week
Weekly
Occasionally
Unsure
When was the last known use?
Have they ever overdosed?
Yes
No
Unsure
Have they ever gone through detox or withdrawal before?
Yes
No
Unsure
What mental health concerns have you noticed
Anxiety
Panic attacks
Depression
Mood swings
Bi-Polar symptoms highs/lows
Manic
Trauma/PTSD
Nightmares or flashbacks
Irritability or anger
Emotional numbness
Shame or guilt
Suicidal thoughts
Self-harm behaviors
Isolation/withdrawing from others
Loss of interest in things they used to enjoy
Trouble sleeping/insomnia
Sleeping to much
Low energy/tired
Difficulty concentrating
Racing thoughts
Paranoia
Hallucinations
Eating concerns
Obsessive thoughts
Compulsive behaviors
ADHD
Focus issues
Memory problems
Poor stress tolerance
Social anxiety
Relationship difficulties
Lack of motivation
Risky or impulsive behavior
Has your loved one ever been diagnosed with a mental health condition?
Yes
No
Unsure
If yes, what diagnoses have they been told they have?
What does your family most want your loved one to work on in treatment?
Emotional regulation
Coping skills
Trauma healing
Anxiety
Depression
Anger management
Grief/loss
Self-esteem
Honesty and accountability
Motivation for recovery
Relapse prevention
Triggers and cravings
Peer influences
Healthy routines
Sleep
Medication stabilization
Family communication
Family trust repair
Boundaries
Life skills
Responsibility
Employment or school goals
Spiritual growth / purpose
Physical health
Aftercare planning
What behaviors are most damaging right now?
Lying
Isolation
Manipulation
Aggression
Stealing
Disappearing / not coming home
Unsafe relationships
Refusing help
Self-harm risk
Relapse
Legal issues
Job/school problems
Other
What are the top 3 issues you most want addressed first?
What patterns keep happening over and over?
What would success in treatment look like to your family?
Are you worried your loved one may be in immediate danger right now?
Yes
No
Unsure
Have they talked about wanting to die or hurt themselves?
Yes
No
Unsure
Have they threatened or harmed others?
Yes
No
Unsure
Are they experiencing hallucinations, paranoia, or severe confusion?
Yes
No
Unsure
Have they had seizures during withdrawal before?
Yes
No
Unsure
Do they have current medical concerns that worry you?
Yes
No
Unsure
Is there domestic violence or an unsafe living environment?
Yes
No
Unsure
Has your loved one been to treatment before?
Yes
No
Unsure
If yes, what levels of care have they done?
Detox
Residential
PHP
IOP
Therapy only
Hospitalization
Other
What seemed to help in the past?
What did not help in the past?
Has your loved one ever left treatment early?
Yes
No
Unsure
What usually gets in the way of them accepting help?
Denial
Fear
Cost
Work/school
Relationship issues
Shame
Withdrawal fears
Legal issues
Transportation
Doesn’t think treatment is needed
Other
What does your family need help with most right now?
Understanding addiction
Understanding mental health
Knowing what to say
Setting boundaries
Preparing for admissions
Family therapy
Communication coaching
Relapse education
Crisis planning
Insurance / logistics
Other
Are you open to family therapy or family sessions?
Yes
No
Unsure
What are your biggest fears right now?
What are your biggest hopes for your loved one?
Is there anything about your loved one’s personality, strengths, or heart that you want the treatment team to know?