personal form

Concerned Person’s Form

Chemical dependency is a disease that causes a person to lose control over their use of alcohol or drugs or other forms of addictive behavior. It is an addiction. This loss of control causes a person to experience physical, psychological, social and spiritual problems. Therefore, the whole person is affected as well as family and friends.
Filling out this questionnaire will give the counselors at Cedars a better understanding of your loved one and will help with their treatment program during their stay with us. To help break through denial and further the patient's treatment, we would like to use this questionnaire to share with the patients and their peers. However, if you prefer this to be kept confidential and not shared, please check the appropriate button below.

I prefer to keep this information confidential

What is it about your loved one's behavior that you disapprove of the most?

Has the patient ever been aggressive or abusive towards you or someone you know?
Please explain in detail.

Has the patient missed any family functions or has any function been affected by their chemical dependence?

Has the patient's work or education been affected?

What are some of the fears you have for this person?

Have you noticed loss of family or friendships because of their chemical dependence?

What do you see as their strengths?

What are your hopes for your loved one?

Is there anything else you would like to share that may help the staff and your loved one?


	Your name:
	Your email address:
	Patient's name:
	Relationship: