| Name (Optional): |
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| Relation to Young Man: |
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| E-mail Address: |
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| Phone Number (Optional): |
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| Young Man’s Name: |
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| Young Man’s Age: |
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| How did you find out about Capstone Treatment Center? |
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| If other, please specify: |
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| What recent events led you to contact us? |
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| Name everything you know that leads you to suspect alcohol and/or drug abuse: |
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| At what age did you first notice that something was changing in the wrong direction? |
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| What else was going on in his life at that time? |
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| What have you tried previously to stop his use of alcohol and/or drugs? |
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| Describe the lies that you have caught him in. Try to be specific in the content of the lie and his exact words as best you can remember. |
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| List all the ways you have attempted to find out what he is doing: |
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| To the best of your knowledge, when was the very first use of alcohol? |
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| Are you sure it was the first use? |
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| To the best of your knowledge, when was the very first use of pot? |
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| If he has used other drugs, list them and the time frame of the very first use. |
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| Are you sure these were the first uses? |
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| Has he ever been treated in a hospital for reasons related to use? |
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| Do you know if he has ever used in the morning? If so, please describe and include how often. |
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| Has he had memory losses? |
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| Did you search his room and car? (old shoes and shoe boxes, in the air vent, old coats and hanging in obvious paces, under the mattress or carpet, and everywhere else). |
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| What did you find? |
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| Have you given him a drug test? |
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| If so, what were the results? If not, why not? |
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| What were his exact words, best you can remember, when he realized you were drug testing him? |
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| Has he distanced from the family in any way? If so, please describe. |
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| If he has mood swings, please describe them. |
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| Does he carry a bottle of visine with him in the vehicle or anywhere else? |
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| Can he open the bedroom or bathroom window as well as the screen? |
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| If so, did you find any signs of drug use? (ashes, burn marks, etc.) |
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| Have any of his friends gotten in trouble for alcohol and/or drugs either by their parents, the school, or the law? |
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| What did they use? |
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| What was your child’s explanation for them getting in trouble? Try to remember their exact words. |
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| Has his sleep patterns changed? If so, how? |
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| Have his eating habits changed? If so, how? |
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| Has he lost a lot of weight in a short period of time? If so, how much in what length of time? |
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| Describe his academic performance including any changes: |
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| Has he gotten in trouble at school? If so, please describe. |
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| What changes have occurred in friendships and groups? |
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| What changes have occurred in extra-curricular activities at school? |
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| What changes have occurred in his hobbies? |
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| How has his dress and appearance changed? |
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| What type of music does he listen to? Names of groups? |
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| How long has he listened to this type of music? |
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| Describe his level of aggression (if applicable): |
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| Describe his level of depression (if applicable): |
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| Has he tried to harm himself? |
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| Has he ever been in trouble with the law? If so, please describe. |
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| If you have noticed a decline in his morals (sexually, dishonesty, work ethic etc.), please describe. |
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| What changes have you noticed in him spiritually? |
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| If he has been involved in church, how has that changed? |
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| Are you working together with another adult to try and solve this problem? If so, what is the relationship of the adult to the young man and to you? |
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| Can you check his Internet use? If so, what sites has he been visiting? |
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| Does he use a cell phone excessively; if so, are there a lot of one minute calls on the bill? |
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| Does he write drug slang and phrases on school notebooks, yearbooks, etc.? |
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| Have you noticed changes in hygiene, taking less care, wearing same clothes over and over, etc.? |
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| Does he show blatant defiance, argumentative or even hostility to parents or other authority figures? |
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| Is he nervous, agitated, or have trouble sitting still? |
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| Is he less hopeful and/or more cynical about life? |
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| Have you noticed his financial management being erratic; spending more, needing more, etc.? |
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| Have you noticed a sudden change in slang; “druggie” behavior observable, profanity? |
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| Do you have any leverage over him that will get him to treatment, for example; legal, financial, etc.? Please describe. |
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