Chemical Dependency Evaluation Interview Form Page 6
ADVERTISEMENT
1
2
3
4
5
6
7G. Legal History
History of traffic violations; including DUI’s
Prior arrests:
Dates:
Consequences:
Has your driver’s license ever been suspended or revoked?
Which?
For what reasons?
History of convictions:
Ever on probation or parole? Dates:
Currently:
Ever been investigated by social service?
Currently:
Any pending legal action?
H. Family History and Social History
Family
Where were you born:
Were you raised in the same place or did you move:
Parent’s employment as you grew up?
Parents style of discipline:
Do you have any siblings: If so which child are you: (exp.–oldest of four)
Current marital status:
How long married:
Significant other’s name:
Remarks about current marriage:
Previous marriages/reasons for breakup (dates):
Children:
Names
Ages
______________________
_______________
______________________
_______________
______________________
_______________
_______________________
_______________
6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business