□ □ YES YES HAS THE COUPLE ATTENDED ANY SUPPORT GROUPS (AL ANON, ETC.) ARE CHILDREN INVOLVED AND CHILDCARE ISSUES ARE NOT A TOGETHER? CONCERN? □ □ NO NO WAS THERE ANY SIGNIFICANT INCIDENTS OR EVENTS THAT LEAD TO THE DECISION TO APPLY FOR COUPLES TREATMENT? WHAT DOES THE COUPLE IDENTIFY AS THE MAIN REASON FOR COMING IN FOR COUPLES TREATMENT? HOW HAS THE COUPLE BEEN PREPARING FOR COMING IN FOR TREATMENT? □ READ RLTC PROGRAM GUIDELINES □ ARRANGED FOR CHILDCARE □ SOUGHT COUNSELLING □ ATTENDED SUPPORT GROUP HOW LONG HAS THE COUPLE BEEN IN THE RELATIONSHIP? IN THE EVENT THAT ONE OF THE PARTNERS LEAVES TREATMENT EITHER BY DISMISSAL OR OWN CHOICE, IS THE OTHER WILLING TO COMMIT TO FINISH □ 6 MONTHS □ 1 TO 4 □ 5 TO 9 YEARS □ 10 TO 15 YEARS □ 20+ YEARS □ □ HIS/HER TREATMENT? YES NO DESCRIBE THE ROLE AND USE OF ADDICTIONS IN THE RELATIONSHIP WHAT HAVE YOU DISCUSSED WITH THE COUPLE REGARDING AFTERCARE PLANS AND COMING BACK INTO THE COMMUNITY AND HOME? □ □ DOES THE COUPLE HAVE A POST-TREATMENT APPOINTMENT SET? YES NO IF YES, DATE OF APPOINTMENT:
HAS THE COUPLE ATTENDED ANY SUPPORT GROUPS (AL ANON, ETC.) TOGETHER? □ YES □ NO ARE CHILDREN INVOLVED AND CHILDCARE ISSUES ARE NOT A CONCERN? □ YES □ NO WAS THERE ANY SIGNIFICANT INCIDENTS OR EVENTS THAT LEAD TO THE DECISION TO APPLY FOR COUPLES TREATMENT? WHAT DOES THE COUPLE IDENTIFY AS THE MAIN REASON FOR COMING IN FOR COUPLES TREATMENT? HOW HAS THE COUPLE BEEN PREPARING FOR COMING IN FOR TREATMENT? □ READ RLTC PROGRAM GUIDELINES □ ARRANGED FOR CHILDCARE □ SOUGHT COUNSELLING □ ATTENDED SUPPORT GROUP HOW LONG HAS THE COUPLE BEEN IN THE RELATIONSHIP? □ 6 MONTHS □ 1 TO 4 □ 5 TO 9 YEARS □ 10 TO 15 YEARS □ 20+ YEARS IN THE EVENT THAT ONE OF THE PARTNERS LEAVES TREATMENT EITHER BY DISMISSAL OR OWN CHOICE, IS THE OTHER WILLING TO COMMIT TO FINISH HIS/HER TREATMENT? □ YES □ NO DESCRIBE THE ROLE AND USE OF ADDICTIONS IN THE RELATIONSHIP WHAT HAVE YOU DISCUSSED WITH THE COUPLE REGARDING AFTERCARE PLANS AND COMING BACK INTO THE COMMUNITY AND HOME? DOES THE COUPLE HAVE A POST-TREATMENT APPOINTMENT SET? □ YES □ NO IF YES, DATE OF APPOINTMENT: