Hiawatha Valley Substance Abuse History Form Page 6
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2
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6Always
Usually
Rarely
Never
Willing to
How often can you count on the following
supportive
supportive
supportive
supportive
stop using
people when you need someone?
Partner/Spouse
Parent(s)/Aunt(s)/Uncle(s)/Grandparent(s)
Sibling(s)/Cousin(s)
Child(ren)
Other relative(s)
Friend(s)/neighbor(s)
Child(ren’s)/father(s)/mother(s)
Support group member(s)
Community of faith members
Social worker/counselor/therapist/healer
Other(specify)
Please describe any family information
(current/past) that might be helpful:
•
Mental/chemical health issues
•
Medical issues
•
Deaths in family
•
Divorces, step-parents
•
Any type of abuse/trauma
Yes
No
If Yes, what religion?
Are you currently religiously affiliated?
GOALS OF THERAPY
Main/Current
Symptoms?
What goals do you
have for your
treatment?
MILITARY HISTORY
Branch:
Served from: ___________ to ____________
Deployment:
10-21-13
P:Form Templates/General Forms/HVMHC General Forms/History Forms
6
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Parent category: Medical