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How many days, in the past 30 days, have you lived with someone who uses alcohol and/or drugs: Days
Who is supportive of client’s recovery:
How many days, in the past 30 days, have you participated in any social support recovery activities (such as 12-step meetings, other self help meetings, religious/faith recovery meetings, meetings of an organization other than those listed above, interactions with family members and/or friend for support of your recovery Days
Specify what type and how often:
Highest school grade completed
Marital Status
How many children do you have aged 5 or less? Children.
How many children do you have aged 17 or less (birth or adopted) whether they live with you or not?
How many children are living with someone else because of a child protective court order?
If you have children living with someone else because of a child protection order, for how many of these children have you parental rights been terminated?
Social Worker’s name/telephone #:
Current living arrangements:
| If enrolled, how many days in the past 30 have you missed school? (0-30) days |
| Employment status: |
| Number of days paid work in past thirty: Days |
| How many days in the past 30 have you had serious conflicts with your family? Days |
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