Concerned Person's FormBelow is a form for significant others to complete in an effort to both help us break through any remaining denial, rationalizations, minimizations, etc., and also to provide a forum for you to be able to discuss how your loved one\u2019s addiction has impacted you. We use the information you provide to better assist us in addressing how your loved one\u2018s addiction manifests in their life and helps us to design a recovery management plan for them moving forward. We encourage members to share this form with their small group of trusted peers. If you prefer the information to be kept confidential please let me know.Please describe your relationship.What is the best time and the best number to reach you at?What is the best time for you to be contacted by the family program counsellor?Process addictions - describe shopping, sex, gambling, internet, work, etc.Why did they decide to seek treatment at this time?What mood-altering chemicals do they currently use - or use prior to them seeking treatment?What is their awareness of the problem?No awareness: \u201cI don\u2019t have a problem. It\u2019s not worse than anybody else\u2019s\u201dMinimal awareness: \u201csure, I\u2019ve had a problem, but I can take it or leave it\u201dModerate awareness: \u201cI have a problem, but I can handle it on my own\u201dAdmits to a problem and accepts responsibility for changeHave they ever made efforts to stop or cut down?How do they obtain money to buy alcohol or other drugs (or to engage in their process addiction)? Has this ever put a strain on family resources?Have they missed any family functions or stopped attending? Have family functions been affected by their addiction?Have any social functions been negatively impacted by their substance use?Have they ever been unable to remember what was done or said while under the influence of substances or while engaged in any addictive behaviors (blackouts)?Has their work ever been affected? If so, how specifically?Have they ever experienced legal problems associated with their addiction?Have they ever become aggressive or abusive as a result of their addiction? Please describe a specific incident(s).What are their behaviors that you disapprove of the most?Has their health been adversely affected by their addiction? If so, how specifically?What do you see as their strengths?Are there any issues that you think could affect their ability to get the most out of their treatment experience or on-going recovery experience once they transition out of Aurora?What are your hopes for them?What are your hopes for your relationship moving forward?What fears, if any, do you have once they transitions out of Aurora?Are there any additional resources you would like to see them participate in once they leave Aurora (i.e. on-going counselling, financial counselling, supportive living\/recovery house, vocational training, legal support, relationship counselling)?Are you able to provide any additional details on how you have been impacted by their substance abuse? What has it been like for you?Information sharing - choose one:I would like to keep this information confidential.I would like to share this information with my loved one.