Welcome to Your Intervention Assessment Questionnaire

Welcome to Your Intervention Assessment Questionnaire

This is the first step towards your complimentary assessment call
You're Taking a Brave Step...

Thank you for being here. We know this isn’t easy, but the fact that you're willing to complete this questionnaire shows just how deeply you care about helping your loved one. You're not alone, and you're not helpless. This process is designed to give you real guidance, based on your family’s unique situation.

Why these questions matter:

The purpose of this questionnaire is to help us understand the patterns, behaviors, and challenges you’ve been facing with your loved one’s substance use. We know how exhausting it is to live in the unknown- and how hard it is to feel unheard or unsure. By answering these questions, you’re giving us the clarity we need to offer the most meaningful, personalized support possible during your call.

What to expect:
- This assessment takes approximately 15-20 minutes to complete.
- You’ll be asked about your loved one’s substance use, family dynamics, past attempts to help, and your emotional experience.
- Every question is designed to give us critical insight so we can truly meet you where you are.
- Your responses are 100% private and confidential. They will only be used to prepare your personalized guidance.
If there’s something you don’t feel ready to answer, that’s okay- but know that the more you share, the more helpful and tailored our response will be.

After You Submit

Once you complete the questionnaire, you’ll receive a link to schedule your complimentary intervention assessment call. On that call, we’ll offer you real, strategic insight based on your responses- with no pressure, no judgment, and no one-size-fits-all advice.

Let's Begin

You’ve already done one of the hardest things: reaching out. Now, let's get the clarity you need to take action.
Your Name*

First NameLast Name
Email*
example@example.com
Today's Date

MonthDayYear
Date
Substance Use Assessment
1. What substances is your loved one using (that you're aware of), and for how long?
2. How often and in what quantities does your loved one appear to use these substances?
3. Have you noticed any signs of withdrawal when they've been unable to use?
4. What specific behaviors or incidents related to their substance use concern you most?
Previous Intervention Attempts
5. What approaches have you already tried to address their substance use?
6. Has your loved one received any prior treatment? If so, what type and what was the outcome?
7. What has been your loved one's typical response when you've tried to discuss their substance use?
8. On a scale of 1-10, how resistant do you expect your loved one to be to getting help?
Family Dynamics & Support
9. What financial or practical support are you currently providing your loved one?
10. Are there other family members involved, and if so, are they aligned with taking action?
11. Is there a history of substance use or mental health disorders in your family? Please provide first names and their relationship to your addicted loved one.
12. What is your loved one's current living situation, and who are their key supports outside the family?
Trauma, Loss & Mental Health
13. Has your loved one experienced any significant traumatic events? (abuse, accidents, violence, etc.)
14. Has your loved one suffered any major losses or disappointments? (death of loved ones, relationship breakups, rejections, failures)
15. Have you noticed signs of grief, anxiety, depression, or other mental health concerns?
16. Does your loved one have any diagnosed mental health conditions or take medications for them?
Consequences & Current State
17. Has your loved one's substance use led to any legal, academic, work, or social consequences?
18. What are the 3 most concerning behaviors you've observed in the last 30-90 days?
19. What boundaries have you tried to set, and how effective have they been?
20. What is your biggest fear about having an intervention?
Goals & Vision
21. What does your ideal outcome look like after having an intervention?
22. What are your goals for your loved one's treatment and recovery?
23. What are your loved one's strengths, interests, and positive coping skills?
24. What resources are you willing and able to provide for treatment if your loved one agrees to get help?
Should be Empty:

Welcome to Your Intervention Assessment Questionnaire

Substance Use Assessment

Previous Intervention Attempts

Family Dynamics & Support

Trauma, Loss & Mental Health

Consequences & Current State

Goals & Vision