Personal & Family Assessment

LIST OF FAMILY MEMBERS LIVING WITH YOU:

REFERRED BY (Please list all referrals including sponsors, therapists, physicians, brochures, friends, etc):
NAME OF PERSON WHO REFERRED YOU:
PHONE NUMBER OF WHO REFERRED YOU:
Please enter a valid phone number.
NAME OF OTHER PERSON WHO REFERRED YOU: (IF APPLICABLE)
PHONE NUMBER OF OTHER PERSON WHO REFERRED YOU: (IF APPLICABLE)
Please enter a valid phone number.
SHORT STATEMENT REGARDING YOUR CURRENT HEALTH AND HEALTH HISTORY (physical and emotional):
ARE YOU TAKING ANY MEDICATION?

YESNO
MEDICATIONS:
DOSAGE:
HOW LONG HAVE YOU TAKEN THIS MEDICATION?
PRESCRIBED BY:
WHY?

CHECK WHERE APPLICABLE:

OTHER PROFESSIONAL HELP? ( please list all)
ARE YOU NOW OR HAVE YOU EVER BEEN CONCERNED ABOUT YOUR OWN DRINKING OR OTHER CHEMICAL USE?
HAS ANYONE ELSE EXPRESSED CONCERN ABOUT YOUR DRINKING OR CHEMICAL USE?
IF SO, PLEASE EXPLAIN:

SHORT STATEMENT REGARDING MAJOR DIFFICULTIES RESULTING FROM OTHER FAMILY:

SHORT STATEMENT REGARDING MAJOR DIFFICULTIES RESULTING FROM ANY OF THESE RELATIONSHIPS:

Page 5 of 7 JIRVANA Workshops
SHORT STATEMENT REGARDING MAJOR DIFFICULTIES RESULTING FROM OTHER FAMILY RELATIONSHIPS (past and present):
FAMILY OF ORIGIN: INDICATE ALL INDIVIDUALS IN YOUR FAMILY WHEN YOU WERE GROWING UP:

PARENTS/ STEP-PARENTS:

	NAME OF PARENTS/STEP-PARENTS	FIVE DESCRIPTIVE ADJECTIVES
1
2
3
4

GRAND PARENTS:

	NAME OF GRAND PARENTS	FIVE DESCRIPTIVE ADJECTIVES
1
2
3
4

OTHER PARENTAL FIGURES

	NAME OF OTHER PARENTAL FIGURES	FIVE DESCRIPTIVE ADJECTIVES
1
2
3

SIBLINGS

	NAME OF SIBLINGS	FIVE DESCRIPTIVE ADJECTIVES
1
2
3

ADULT LOVE RELATIONSHIPS (not already mentioned)

	NAME OF LOVE RELATIONSHIP	FIVE DESCRIPTIVE ADJECTIVES
1
2
3
4

SHORT STATEMENT REGARDING MAJOR DIFFICULTIES RESULTING FROM OTHER RELATIONSHIPS (past and present):
DESCRIBE YOURSELF:*
EXPECTATIONS OF THE PROGRAM:*
DATE:*

MonthDayYear
Date
SIGNATURE:*

Clear
Page 7 of 7 JIRVANA Workshops

(PLEASE LEAVE BLANK FOR STAFF TO COMPLETE)
THERAPIST'S ASSESSMENT:
THERAPIST'S SIGNATURE

Clear
Should be Empty: