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Family Sharing:
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This exercise is called family sharing because, unlike your other assignments, it is intended to be shared with and answered by your wife, husband, children, parents, or other family members or friends. These questions are to be answered as they pertain to your use of alcohol, and will focus on how your drinking affects those people around you. One of the goals of this program is to assist you in learning all you can about your use of alcohol. Thus it becomes important for family and friends to discuss and share with you how they feel about your use of alcohol. (Printable version) Name of person(s) filling out this form: ______________________________ Relationship of person(s) who filled out this form: _____________________ |
Please answer these questions as they apply to the client's use of alcohol: |
Yes | No |
| 1. Are you often worried and annoyed about this person's drinking? | ||
| 2. Does this person's drinking cause embarrassment? | ||
| 3. Are holidays often spoiled by over drinking? | ||
| 4. Are most of the person's friends heavy drinkers? | ||
| 5. Does the person promise to quit drinking without success? | ||
| 6. Does drinking make the home atmosphere tense and anxious? | ||
| 7. Does the person deny a problem because it's "only beer"? | ||
| 8. Do you find it necessary to lie and cover-up the drinking? | ||
| 9. Does the person ever fail to remember things when or after drinking? | ||
| 10. Does the person avoid discussions about alcohol and problems? | ||
| 11. Does the person attempt to justify his/her drinking problem? | ||
| 12. Does the person avoid situations where alcohol is unavailable? | ||
| 13. Do you ever feel guilty about the person's actions? | ||
| 14. Has this person ever driven a car while under the influence? | ||
| 15. Are the children afraid when the person is drinking? | ||
| 16. Are you afraid of verbal or physical abuse from the person? | ||
| 17. Have other people mentioned the person's unusual behavior? | ||
| 18. Do you fear riding in a car when this person has been drinking? | ||
| 19. Does the person have periods of remorse and try to apologize? | ||
| 20. Does the person seem to drink larger quantities than in the past? | ||
| 21. Does the person appear to become affected now by smaller quantities of alcohol than in the past? |
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