In order to treat you effectively, I need information about the ways you and your family have used alcohol, drugs, and/ or other chemicals that can affect you psychologically. So please answer these questions fully.
A. What have you used?
1. Think about any and all chemicals you have used, and indicate how much you used (amount) and how often. Then indicate all the effects it had on you (mental, physical, family, legal, etc.).
C. Family patterns of chemical use
*In the fourth column, use these codes: AA/NA = Alcoholics Anonymous/Narcotics Anonymous; O = Outpatient counselling; ID = Inpatient detoxification; IT = Inpatient treatment (e.g., 28-day); O = Other.
**In the last column, use these codes: W = made situation Worse; N = No change; U = better Understanding of addiction; R = Reduction of use; BA = Brief abstinence (up to a month); LA = Long-term abstinence (several months or more); O = Other effects:
F. Self-description of use