Eyewitness Information

Thank you for participating in getting your loved one help. A key component to helping is gathering together each participant’s eyewitness account. So please answer the following questions as completely as you are able. When you’re through, please click on the ‘submit’ button and the information will be securely forwarded to our team.

Identified Loved One

RELATIONSHIP TO IDENTIFIED LOVED ONE

FIRST NAME

LAST NAME

YOUR EMAIL

CELL PHONE

ALTERNATE PHONE

Address

STREET ADDRESS

ADDRESS LINE 2

CITY

STATE / PROVINCE / REGION

ZIP / POSTAL CODE

COUNTRY

Step 2: Loved one's history

DRUG(S) OF CHOICE:

PRESCRIPTION MEDICATIONS

GENERAL HEALTH:

SMOKER?(Required)

Yes

IF SMOKES, HOW MUCH? WHICH BRAND?

DESCRIBE PAST TREATMENTS OR THERAPY HISTORY (IF ANY):

DOES YOUR LOVED ONE HURT HIM/HERSELF OR OTHERS?

POLICE INCIDENT(S):

ALL ARRESTS:

ANY PENDING LEGAL ISSUES?

TIME IN JAIL?(Required)

Yes

ALL AUTOS AND/OR PERSONAL ACCIDENTS:

DOMESTIC VIOLENCE:

SUICIDAL TALK/ATTEMPTS:

IF YES, WHEN/WHERE?

DANGEROUS BEHAVIORS:

WEAPONS?

Step 3: What Have You Witnessed?

WRITE DOWN A BRIEF DESCRIPTION OF THE PROBLEM FROM YOUR VANTAGE POINT:

WRITE DOWN ALL COSTS YOU AND/OR YOUR FAMILY HAVE EXPERIENCED AS A RESULT OF THE PROBLEM:

WHAT FAMILY ISSUES DO YOU SEE?

WHAT DO YOU THINK YOUR IDENTIFIED LOVED ONE'S PRIMARY RESERVATION IS IN ACCEPTING HELP?

TO BETTER UNDERSTAND THE GROUP DYNAMIC, WHAT ISSUES ARE YOU DEALING WITH IN YOUR OWN LIFE AROUND ADDICTION OR BEHAVIOR THAT YOU WANT TO CHANGE?

LIST THE PEOPLE WHOSE VOICES MATTER THE MOST IN YOUR LOVED ONE'S LIFE:

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Eyewitness Information

Identified Loved One

Address

Step 2: Loved one's history

Step 3: What Have You Witnessed?

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