Confidential Survey
Submission of this survey on line is optional however, you will be required to complete it if accepted by Good Samaritan Rehabilitation. All information submitted in this survey will be kept in the strictest confidence. The information gathered through this form will enable us to further understand you and many others like you.
Date *
Name *
Age *
How many times have you been in jail *
Are you married *
Have you ever been suicidal? *
What is your purpose in life? *
Do you have children? *
How many *
Were your parents married when you were born? *
Did your parents get a divorce? *
Are both of your parents alive *
If no, which parent has died?
Clear selection
Were either of your parents addicted to drugs? *
If yes, which parent?
Clear selection
what drug(s) did your parent(s) use?
Did your parents drink alcohol? *
If yes, which one?
Clear selection
Are (or were) your parent(s) alcoholic(s) *
If yes, which one?
Clear selection
Have you ever committed adultery on your mate? *
How many times have you been married? *
estimate how many people you have had intimacy with in your life. *
Do you have children out of wedlock? *
How Many *
Are you in trouble with the law? *
What are your charges?
Have you lost all your money? *
Have you lost your drivers license? *
Your car *
Did your mate leave you?
Clear selection
Are you employed? *
What is your occupation or trade? *
Have you lost your home? *
Have you been abused? *
Please check all that apply
Have you been diagnosed with anything? *
Describe what. *
Do you drink or use tobacco? *
Check all that apply
What age did you first use drugs/alcohol? *
Do you want to stop using? *
Does your mate?
Clear selection
What is your drug of choice? *
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