Addiction Intervention & Family Services

(760) 880-9190

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Online Assessment Form

Please fill out the form below as completely as possible, or Dr. Jim Tracy may be reached at (760) 880-9190.

Loved One Information
Name (First, Last)*
DOB (mm/dd/yyyy)*
Current Address
Street Address Address Line 2 City State ZIP Code
Known Substances Being Used*
Other Issues and/or Mental Health Diagnoses (Depression, Bi-Polar Disorder, etc)
Prescribed Medications (click + to add more rows)
Medication Current RX# Dosage Reason Start/End Physician
Has this person ever experienced trauma or been the victim of abuse?
- Yes
- No
Please explain:*
Occupation
Is the employer aware of the addiction?
- Yes
- No
Highest level of education achieved
Marital Status
Number of children
Previous Treatment History (click + to add more rows)
Where When Why Completed?
Has this person ever attempted self-harm or suicide?
- Yes
- No
Please explain, including approximate dates:*
Please list this person's legal problems, both past and current:
Is this person currently on probation?
- Yes
- No
Is there a family history of substance abuse or mental health issues?
- Yes
- No
Please explain:*
Your Information
Name (First, Last)*
Relationship to the individual*
Email Address*
Current Address
Street Address Address Line 2 City State ZIP Code
Cell Phone
Is it okay to leave messages on your cell phone?
- Yes
- No
Home Phone
Is it okay to leave messages on your home phone?
- Yes
- No
Are you financially sponsoring this individual?*
- Yes
- No
Name of financially responsible party
Phone
Address
Street Address Address Line 2 City State ZIP Code
Email Address
Please explain the event(s) that led you to seek help for your loved one
If your loved one continues in his or her addiction, what do you expect the consequences to be?
Participants in the Intervention (click + to add more rows)
Name Age Relationship Cell Phone Email
Is there anyone who could potentially sabotage the intervention or treatment for your loved one?
- Yes
- No
Please provide more information, including what way(s) they could sabotage our efforts to help your loved one*
Please enter the text below:

Loved One Information
Name (First, Last)*
DOB*
MM
DD
YYYY
Current Address
Street Address Address Line 2 City State ZIP Code
Known Substances Being Used*
Other Issues and/or Mental Health Diagnoses (Depression, Bi-Polar Disorder, etc)
Prescribed Medications (click + to add more rows)
Med/ RX# Dosage/ Reason Start/End/ Physician
Has this person ever experienced trauma or been the victim of abuse?
- Yes
- No
Please explain:*
Occupation
Is the employer aware of the addiction?
- Yes
- No
Highest level of education achieved
Marital Status
Number of children
Previous Treatment History (click + to add more rows)
Where When Why
Has this person ever attempted self-harm or suicide?
- Yes
- No
Please explain, including approximate dates:*
Please list this person's legal problems, both past and current:
Is this person currently on probation?
- Yes
- No
Is there a family history of substance abuse or mental health issues?
- Yes
- No
Please explain:*
Your Information
Name (First, Last)*
Relationship to the individual*
Email Address*
Current Address
Street Address Address Line 2 City State ZIP Code
Cell Phone
Is it okay to leave messages on your cell phone?
- Yes
- No
Home Phone
Is it okay to leave messages on your home phone?
- Yes
- No
Are you financially sponsoring this individual?*
- Yes
- No
Name of financially responsible party
Phone
Address
Street Address Address Line 2 City State ZIP Code
Email Address
Please explain the event(s) that led you to seek help for your loved one
If your loved one continues in his or her addiction, what do you expect the consequences to be?
Participants in the Intervention (click + to add more rows)
Name/ Relationship Cell Phone Email
Is there anyone who could potentially sabotage the intervention or treatment for your loved one?
- Yes
- No
Please provide details, including what way(s) they could sabotage our efforts to help your loved one*
Please enter the text below:

Medication	Current RX#	Dosage	Reason	Start/End	Physician

Where	When	Why	Completed?

Name	Age	Relationship	Cell Phone	Email

Med/ RX#	Dosage/ Reason	Start/End/ Physician

(760) 880-9190

Online Assessment Form

Loved One Information

Your Information

Loved One Information

Your Information