Family Intervention and Crisis Prevention Family Intervention and Crisis Prevention Warning: Please avoid using your Back Button while in this form, use the buttons below. If you are exploring your options and have questions about Family Intervention Services, the following questionnaire will help you clarify your concerns and give me an idea just how to formulate you an intervention plan. Your contact info is required so that I can respond to your call for help! (Use an alias [fake name] if you wish to hide your identity) Step 1 of 3 33% Disclaimer* I've read the 'Confidentiality Disclaimer' on the right. Name First Last Email PhoneWho are you concerned about?Contact InfoName (If you wish) First Last Relationship to YouDrug of ChoiceAgeAll questions below are optional! Just provide as much information as you wish. You may leave any of the below questions blank. Remember, you may wish to reserve for later your most guarded secrets. You can assure your utmost confidentiality by saving some information for our personal-private counseling sessions!If you are concerned about a substance abuse problem, please summarize the drugs being used, the amounts and frequency of use if you can. If this is a mental health issue, what is the nature of this challenge? (depression, social anxiety, bipolar disorder, schizophrenia?) Please check any of the below symptoms that apply. Marital Problems Sexual Problems Financial Problems Passing Out Social Problems Personality Changes Medical Problems Depression or Anxiety Occupational Problems Shame and Embarrassment Relationship Problems Children Negatively Impacted Legal Problems Describe other high-risk behaviors that are of concern to you.How has this person’s symptoms affected other family members, friends or colleagues?What impact has this problem had on social, legal, academic, medical or occupational functioning? How have you attempted to help resolve solve this problem on your own? Have you offered help? Can you discuss this problem without igniting angry defenses, denial, avoidance or secretive drug use?If the person you are concerned about is noted for a history of mental health problems or psychiatric hospitalization, please summarize them below.What do you want to see happen as a result of your intervention counseling with me? It is best if I know in advance what you hope to accomplish as a result of our work?What do you predict will happen if nothing changes for the positive?EmailThis field is for validation purposes and should be left unchanged.