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Family questionnaire

Home Family Questionnaire

Dear family member/loved one,

Welcome to Recovery Centers of America (RCA). We applaud your family member’s decision to enter treatment and understand that it may not have been an easy one. We understand that, for many of you, this is an entirely new experience filled with hope but also, concern. For some of you, this may not be the first time you’ve tried to support your loved on in quitting drugs or alcohol. Either way- at RCA, we embrace families because they play a major role in their loved one’s recovery. Family support and participation is associated with increased success in treatment and lasting recovery.

The intention of this questionnaire is to obtain information that will assist us in creating both your loved one’s treatment plan. Please let us know if you would prefer that your answers not be shared with the patient.

Let’s learn about your loved one and family

*We are going to use the term “family member” throughout this document to refer to anyone who can provide support and information about the patient.

Family Questionnaire

Patient's Name(Required)
Patient's Date of Birth(Required)
Your Name(Required)
Are you currently living with the patient?
Did your loved one complete treatment each time?
Have you ever received support or education about Substance Use treatment and recovery?
Do you feel your loved one needs treatment?
Is there anyone in the family who feels differently than you?

Expectations of Treatment

People RCA Should Know About

Please identify 5 people who are positive, healthy and supportive of the recovery process both for your loved one in treatment as well as the family:
First Name
Last Name
Relationship
Phone
E-mail
 
Are there any relationships you feel put your loved one at risk or are a negative influence on their recovery process? If so, why?
First name
Last Name
Reason Why
 

About You

Your Address(Required)
Your Email(Required)
Are you comfortable with us sharing information from this questionnaire with your love one?
X
 

X

Treatment Advisor
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