Hiawatha Valley Substance Abuse History Form Page 5
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6Do you have a sponsor?
Yes
No
Any history of suicide in your family?
Yes
No
Or, someone close to you?
Yes
No
Are thoughts of suicide occurring when under the influence?
Yes
No
Legal history: List current/recent history of any legal problems related to substance use.
CLIENT CHOICE/EXCEPTIONS
What obstacles exist to participating in treatment? (Time off work, childcare, funding, transportation, pending jail time, living
situation)
What particular treatment choices and options would you like to have?
Do you have a preference for a particular treatment program?
Have you had other rule 25 assessments?
Yes
No
If yes, where and what circumstances?
FAMILY RELATIONSHIPS
N/A (Child)
Single
Married
Widow
Divorced
Relationship status:
(check as many as apply)
In a significant relationship
Separated from partner Date __________
If you are in a relationship, please
Partner's Name:
How long in relationship: ______
complete:
Please list all people with whom you
Name(s)
Age(s)
Relationship to person receiving
services
currently live with.
Name(s)
Age(s)
Relationship to person
Please list parents, brothers and sisters who
receiving services
are not currently living in your home.
Are you adopted?
Yes
No
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Parent category: Medical