BWR Family Questionnaire
Patient's Name
*
Your Name
*
Your Phone
-
Area Code
Phone Number
Your E-mail
*
example@example.com
Your Relationship to Patient
*
How many years have you been in a relationship with the patient?
Do you live with this patient?
Yes
No
Please list all persons living with the patient, their relationship to the patient and whether any of them abuse
Do you intend on continuing to live with the patient after his/her treatment?
Yes
No
N/A
How many children live in the home and what are their ages?
HOW OFTEN HAVE THE FOLLOWING OCCURRED?
Does your family member have mood swings?
Not at all
Once or twice
Sometimes
Often
Don't know
Does your family member have poor communication skills?
Not at all
Once or twice
Sometimes
Often
Don't know
Does your family member steal money or items, or borrow money and not pay it back?
Not at all
Once or twice
Sometimes
Often
Don't know
Have the family’s finances been affected?
Not at all
Once or twice
Sometimes
Often
Don't know
Does your family member pick quarrels with you?
Not at all
Once or twice
Sometimes
Often
Don't know
Has your family member threatened you physically or emotionally?
Not at all
Once or twice
Sometimes
Often
Don't know
Has it been necessary for people outside the family, or agencies, to get involved?
Not at all
Once or twice
Sometimes
Often
Don't know
Does your family member come and go at irregular or awkward times?
Not at all
Once or twice
Sometimes
Often
Don't know
Does your family member’s drinking/drug use get in the way of your social life?
Not at all
Once or twice
Sometimes
Often
Don't know
Has your family member missed or upset family occasions?
Not at all
Once or twice
Sometimes
Often
Don't know
Does your family member fail to participate in family activities?
Not at all
Once or twice
Sometimes
Often
Don't know
Has your family member been late or unreliable?
Not at all
Once or twice
Sometimes
Often
Don't know
Are you worried that your family member’s ability to work or study has been affected by drinking/drug use?
Not at all
Once or twice
Sometimes
Often
Don't know
Are you worried that your family member’s physical health has been affected by the drinking/drug use?
Not at all
Once or twice
Sometimes
Often
Don't know
Are you worried that your family member has neglected his/her/her appearance, hygiene, or self-care?
Not at all
Once or twice
Sometimes
Often
Don't know
Are you worried that your family member’s mental state is affected by drinking/drug use?
Not at all
Once or twice
Sometimes
Often
Don't know
HAVE YOU EVER...
Refused to lend him/her money or to help him/her out financially in other ways?
No
Once or twice
Sometimes
Often
Put the interests of other members of the family before his/her?
No
Once or twice
Sometimes
Often
Put yourself out for him/her, for example by getting him/her to bed or by clearing up messes after him/her?
No
Once or twice
Sometimes
Often
Given him/her money even when you thought it would be spent on substances?
No
Once or twice
Sometimes
Often
Sat down together with him/her and talked frankly about what could be done about his/her substance abuse?
No
Once or twice
Sometimes
Often
Started an argument with him/her about his/her substance abuse?
No
Once or twice
Sometimes
Often
Pleaded with him/her about decreasing or stopping his/her consumption of substances?
No
Once or twice
Sometimes
Often
When he/she was under the influence of substances, left him/her alone to look after him/herself or stayed out of his/her way?
No
Once or twice
Sometimes
Often
Made it quite clear to him/her that his/her substance abuse was upsetting you and that it had to change?
No
Once or twice
Sometimes
Often
Felt too frightened to do anything?
No
Once or twice
Sometimes
Often
Tried to limit his/her drinking by making some rule about it; for example, forbidding the use of substances in the house, or stopping him/her from bringing friends who use substances home?
No
Once or twice
Sometimes
Often
Stopped pursuing your own interest or looking for new interests or new relationships?
No
Once or twice
Sometimes
Often
Encouraged him/her to take an oath or promise not to drink?
No
Once or twice
Sometimes
Often
Felt too hopeless to do anything?
No
Once or twice
Sometimes
Often
Avoided him/her as much as possible because of his/her substance abuse?
No
Once or twice
Sometimes
Often
Got moody or emotional with him/her?
No
Once or twice
Sometimes
Often
Watched his/her every move or frequently checked up on him/her?
No
Once or twice
Sometimes
Often
Became involved in your own things or acted as if he/she wasn’t there?
No
Once or twice
Sometimes
Often
Made it clear that you won’t accept his/her reasons for drinking, or cover up for him/her?
No
Once or twice
Sometimes
Often
Made threats that you didn’t really mean to carry out?
No
Once or twice
Sometimes
Often
Made it clear to him/her of your expectations of how he/she should contribute to the family?
No
Once or twice
Sometimes
Often
Protected him/her or stood by him/her when others were criticizing him/her?
No
Once or twice
Sometimes
Often
Became unable to make any decisions?
No
Once or twice
Sometimes
Often
Accepted the situation as a part of life that couldn’t be changed?
No
Once or twice
Sometimes
Often
Accepted the situation as a part of life that couldn’t be changed?
No
Once or twice
Sometimes
Often
Sat down with him/her to help sort out the financial situation?
No
Once or twice
Sometimes
Often
When things have occurred due to his/her drinking, have you made excuses for him/her, covered up for him/her, or taken the blame yourself?
No
Once or twice
Sometimes
Often
Searched for his/her substances, or hidden or disposed of it yourself?
No
Once or twice
Sometimes
Often
Sometimes put yourself first by looking after yourself or giving yourself treats?
No
Once or twice
Sometimes
Often
Tried to keep things looking normal and pretended all was well when it wasn’t, or hidden the extent of his/her drinking?
No
Once or twice
Sometimes
Often
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BWR Family Questionnaire (Cont.)
How has the patient’s substance abuse affected the child/children? Please describe.
Do the children have any problems with personality, emotions, or school/work? Please describe.
What is the patient’s drug of choice?
Which substances does the patient use and what is the frequency and amount used of each substance?
How long have you been aware of the patient’s substance use and how did you become aware of it?
Which previous substance abuse treatments has the patient undergone?
What is the longest period of time that you are aware of that the patient was not using mood-altering substances?
Does the patient have any medical or psychiatric issues? Please describe.
Does the patient have legal, employment, or financial issues related to substance abuse? Please describe.
What have you done to help the patient with his/her substance use?
How have the patient’s recreational activities and social relationships been affected by his/her use? Please describe.
How has the patient’s substance abuse affected your life?
Are you attending any type of therapy, counseling, or self-help groups? Please describe.
Are you taking any addictive prescription medications? Please describe.
How much and how often do you drink alcohol?
Are you using any illicit substances? If so, which substances and how often?
What are your goals for the patient’s treatment?
What do you believe will help the patient be successful in his/her recovery?
What do you believe are the barriers to the patient’s recovery?
What are your expectations for the patient, and your relationship with the patient after his/her discharge from treatment?
Describe two or three episodes that best characterize the patient’s behaviors while he/she is using substances.
Please write any additional comments or information that you feel is pertinent to the patient’s recovery/treatment.
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