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

  • Expectations of Treatment

  • People RCA Should Know About

  • First NameLast NameRelationshipPhoneE-mail 
  • First nameLast NameReason Why 
  • About You

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