Family Intake Questionnaire

Please provide names, ages, and nature of relationship, e.g., father, brother, aunt, friend, coach, or teacher. Provide details if the significant relationship ended in a way that impacted your loved one.

This question is for the mother or father of the client. Information includes whether the pregnancy was full term, weight at delivery, and whether or not the mother or parents were under unusual stress at the time. This information is useful to rule out contributors to present medical and psychiatric conditions. Please write “unknown” if you are not the mother or do not know.

Here we are looking at whether your loved one, as a toddler, achieved normal developmental milestones at an appropriate age.

Useful information includes interests, sports, hobbies, socialization, academic performance, and general interest in school.

Useful information is similar to Elementary School Years, but can also include romantic relationships and use of substances. Please include significant events or changes in behaviour that may have contributed to your loved one’s current situation.

Useful information is similar to Middle School Years. Please include significant events or changes in behaviour that may have contributed to your loved one’s current situation.

Include details of what your loved one has done post-high school. Details may include work, post-secondary education, achievements, and struggles. Please include romantic relationships and children (if any), including interpersonal struggles with partners and/or children. Include any adulthood mental health or medical conditions, possible contributing factors or events, and what supports your loved one accessed during these times. Please detail if your loved on attended other residential programs, hospital-based services, hospitalizations, or outpatient services including approximate dates.

Please detail what you believe motivated your loved one to seek (or agree to attend) our program. A precipitating event could have occurred several years ago, but your loved one may have only decided to seek help recently. More often than not, our clients seek treatment due to a significant event, such as the end of a romantic relationship, hospitalization, job termination, or a combination of events.

Please include any comments you would like to add. These may include your loved one’s strengths, what you hope your loved one addresses during treatment, arrangements you hope your loved one will make after discharge (e.g. enter a sober living facility), etc. If your loved one is an alumnus, please use this section to describe changes since their last treatment and any ongoing struggles, etc.