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 *
Your answer
Name *
Your answer
Age *
Your answer
How many times have you been in jail *
Your answer
Are you married *
Have you ever been suicidal? *
What is your purpose in life? *
Your answer
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?
Were either of your parents addicted to drugs? *
If yes, which parent?
what drug(s) did your parent(s) use?
Your answer
Did your parents drink alcohol? *
If yes, which one?
Are (or were) your parent(s) alcoholic(s) *
If yes, which one?
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. *
Your answer
Do you have children out of wedlock? *
How Many *
Your answer
Are you in trouble with the law? *
What are your charges?
Your answer
Have you lost all your money? *
Have you lost your drivers license? *
Your car *
Did your mate leave you?
Are you employed? *
What is your occupation or trade? *
Your answer
Have you lost your home? *
Have you been abused? *
Please check all that apply
Have you been diagnosed with anything? *
Describe what. *
Your answer
Do you drink or use tobacco? *
Check all that apply
What age did you first use drugs/alcohol? *
Your answer
Do you want to stop using? *
Does your mate?
What is your drug of choice? *
Your answer
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