Gambling Relationships Shopping    Sex Food Internet Other: ______________________________    Impact: Which areas have been negatively affected by your use? School Attendance Physical Health Family Relationships Legal Situation     Employment Psychological Health Friendships Parenting     Other ____________________________________________________________________________________ Situation: Did you drink or use drug… Alone With boss With parents With Cousins     At home With Co-workers With Grandparents With Uncles-aunts     At parties With Strangers With Spouse On weekdays     In bars In large groups With Brothers/Sisters On weekends     At work With small groups With Friends    Family of Origin use History: Is there any history of alcohol/drug use in your family of origin? Yes No   Relatives Uses Uses Never Deceased. In close Some No contact alcohol met this Year of death: contact contact relative Grandmothers: Grandfathers: Bio Mother Adoptive Mother Bio Father Adoptive Father Foster Parents Brothers: Sisters: Children: Risk Assessment:
Gambling  Relationships  Shopping  Sex  Food  Internet  Other: ______________________________ Impact: Which areas have been negatively affected by your use? School Attendance  Physical Health  Family Relationships  Legal Situation  Employment  Psychological Health  Friendships  Parenting  Other ____________________________________________________________________________________ Situation: Did you drink or use drug… Alone  With boss  With parents  With Cousins  At home  With Co-workers  With Grandparents  With Uncles-aunts  At parties  With Strangers  With Spouse  On weekdays  In bars  In large groups  With Brothers/Sisters  On weekends  At work  With small groups  With Friends  Family of Origin use History: Is there any history of alcohol/drug use in your family of origin? Yes  No  Relatives Uses alcohol Uses Never met this relative Deceased. Year of death: In close contact Some contact No contact Grandmothers: Grandfathers: Bio Mother Adoptive Mother Bio Father Adoptive Father Foster Parents Brothers: Sisters: Children: Risk Assessment:
APPLICATION_FOR_SERVICES.docx