Concerned Persons Form

Addiction is a disease that leads individuals to lose control over their use of alcohol, drugs, or other addictive behaviors, causing physical, psychological, social, and spiritual issues. This loss of control affects not only the individual but also their family and friends.

By completing this questionnaire, you provide Lakeview counselors with valuable insights into your loved one, aiding in their treatment program. To help address denial and enhance treatment, we may share this information with residents and their peers. If you prefer to keep this information confidential, please check the appropriate box below.

Information Consent

I consent to this information be shared only with my loved one's clinician.

I prefer this information remain between myself and my loved one's clinician. However, I would be interested in disclosing and processing it upon the initiation of a family conference or crisis call.

I consent to sharing this information with my loved one, so they may process it in a safe and therapeutic setting with their clinician independent of my availability.

Resident Name

Resident First Name

Resident Last Name

What is it about your loved one's behaviour in addiction that you find most challenging?

Has the resident ever been aggressive or abusive towards you or someone you know? Please explain in detail.

Has the resident missed any family functions or has any function been affected by their chemical dependence?

Has the resident's work or education been affected?

What are some of the fears you have for this person?

Have you noticed loss of family or friendships because of their chemical dependence?

What do you see as their strengths?

What are your hopes for your loved one?

Is there anything else you would like to share that may help the staff and your loved one?

Your Name

First Name:

Last Name:

Relationship to Resident

Concerned Persons Form

Resident Name

Your Name

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