Questionnaire Part Two
(All boxes with asterisks **** must be filled.)

You must complete Questionnaire Part One first.

First name:  ****     Last name: 

Email address:           ****

Email address again:   ****     

More Alcohol & Drug History:

1. Tell me about any substance abuse or addiction treatment you have received -  inpatient, outpatient, detox, AA, NA - when, where and why. If none, write "none."

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2. Tell me about any legal problems you have had as a result of alcohol or drugs  (arrests while intoxicated, DUIs, DWIs, possession, assaults, distribution, etc.). If none, write "none."

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3. Tell me about any family history of addiction, substance abuse, or mental illness, including any diagnoses, rehabs, suicide attempts, or psychiatric hospitalizations. If none, write "none."

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Social History:

4. Tell me who raised you, who was in the household growing up; tell me about your siblings and where you were in the birth order; tell me about your parents' divorces, separations, deaths, and whatever else you think is significant about your growing up years.

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5. Paint a picture for me of what your childhood felt like - possibly in a metaphor. I really want to know what you childhood felt like to you. Then, tell me what made it that way.

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6. Tell me about your mother, stepmother, and/or other significant female care providers. What were their personalities like, how did they live, how did they treat you, and what has been your relationship with them over the years including now?

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7. Tell me about your father, stepfather, and/or other significant male care providers. What were their personalities like, how did they live, how did they treat you, and what has been your relationship with them over the years including now?

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8. Tell me about your romantic relationships over the years, and in particular about any patterns you have noticed. Examples: "I'm always attracted to losers." or "I always seem to sabotage my relationships just when they're getting good." Tell me about the course of any marriages and divorces, and the personalities and behaviors of your significant others.

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9. Who are the three people you would turn to if you needed to discuss an extremely painful event or situation? Tell my why you would choose these people.

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10. How far did you go in school and what have been the patterns of your work history as an adult?

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11. Describe any legal (criminal) problems you have ever had - the crime, the punishment, and other consequences.  Describe any violent behavior you have ever exhibited. If none, write "none."

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12. Tell me about ever being sexually or physically abused. If never, write "never."

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13. Tell me about your hobbies and interests. What do you like to do for fun and relaxation? If none, write "none."

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14. Tell me about your religious or spiritual beliefs. If none, write "none."

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