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Patient Information Form Date ___________ Last Name: First Name: Middle Initial: Date of Birth: Social Security Number: _________- _________-____________ Gender: Male Female TG / M F TG / F M Primary Phone # ( _____)____________________________ Cell Home Work OK to leave message? Yes No OK to Text? Yes No Secondary Phone # ( )______________________ Cell Home Work OK to leave message? Yes No OK to Text? Yes No Email Address: ____________________________________________ @__________________________ OK to send Email Physical Address: City: State: Zip Code: Mailing Address: (if different from above): Check here if you DO NOT authorize mailings from Family Centers Inc. Occupation (if employed): ___________________________________________ Full Time Part Time N/A School (if student) __________________________________________________ Full Time Part Time N/A Emergency Contact Name: ________________________________________________ Relationship to Patient: ___________________ Emergency Contact Primary Phone # ____________________________Cell Home Work OK to leave message: Yes No Secondary Phone # ___________________________________________Cell Home Work OK to leave message: Yes No Type of Residence where you live: Home/Own Rent Friends/Family Transitional Homeless Shelter Other _________________________ Public Housing Yes No Section 8 Yes No Do you think of yourself as: Lesbian, Gay or Homosexual Straight or Heterosexual Bisexual Something Else Don’t Know Primary/Preferred Language if other than English: __________________________________ Do you need a Translator: Yes No Are you a veteran of one of the United States Uniformed Services? Yes No How did you hear about us? Friend/Family member Media Internet Family Centers Event/Outreach Referred by other Agency: Agency Name________________________ Other: Who referred you? ______________________ Annual Household Income: $ Number of people in the household: Ethnicity: (Choose One) Hispanic Non-Hispanic Race: (choose all that apply) White/Caucasian Black/African American Asian Native Hawaiian American Indian or Alaskan Native Other Pacific Islander Marital Status: Single Unmarried Couple Married (Spouse Name_______________________) Separated Widowed Divorced

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Page 1: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

                             Patient Information Form Date ___________ 

Last Name: First Name: Middle Initial:

Date of Birth: Social Security Number: _________- _________-____________

Gender: ☐ Male ☐Female ☐TG / M F ☐TG / F M

Primary Phone # ( _____)____________________________ ☐Cell ☐Home ☐Work

OK to leave message? ☐Yes ☐No OK to Text? ☐Yes ☐No

Secondary Phone # ( )______________________

☐Cell ☐Home ☐Work

OK to leave message? ☐Yes ☐No OK to Text? ☐Yes ☐ No

Email Address: ____________________________________________ @__________________________ ☐ OK to send Email

Physical Address:

City: State: Zip Code:

Mailing Address: (if different from above): ☐ Check here if you DO NOT authorize mailings from Family Centers Inc.

Occupation (if employed): ___________________________________________ ☐ Full Time ☐ Part Time ☐ N/A

School (if student) __________________________________________________ ☐ Full Time ☐ Part Time ☐ N/A

Emergency Contact Name: ________________________________________________ Relationship to Patient: ___________________

Emergency Contact Primary Phone # ____________________________☐Cell ☐Home ☐ Work OK to leave message: ☐Yes ☐ No

Secondary Phone # ___________________________________________☐Cell ☐Home ☐Work OK to leave message: ☐Yes ☐ No

Type of Residence where you live:

☐ Home/Own

☐ Rent

☐ Friends/Family

☐ Transitional

☐ Homeless

☐ Shelter

☐ Other _________________________

Public Housing ☐ Yes ☐ No

Section 8 ☐ Yes ☐ No

Do you think of yourself as:

☐Lesbian, Gay or Homosexual

☐ Straight or Heterosexual

☐ Bisexual

☐ Something Else

☐ Don’t Know

Primary/Preferred Language if other than English: __________________________________

Do you need a Translator: ☐ Yes ☐ No

Are you a veteran of one of the United States Uniformed Services? ☐ Yes ☐No

How did you hear about us?

☐Friend/Family member

☐ Media

☐ Internet

☐ Family Centers Event/Outreach

☐ Referred by other Agency:

Agency Name________________________

☐ Other:

Who referred you? ______________________

Annual Household Income: $ Number of people in the household:

Ethnicity: (Choose One)

☐ Hispanic☐Non-Hispanic

Race: (choose all that apply)

☐ White/Caucasian

☐ Black/African American

☐ Asian

☐ Native Hawaiian

☐ American Indian or Alaskan Native

☐ Other Pacific Islander

Marital Status:

☐ Single

☐ Unmarried Couple

☐ Married (Spouse Name_______________________)

☐ Separated

☐ Widowed

☐ Divorced

Page 2: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

HEALTH INFORMATION

Revised 1/8/2018

Date: _________________

Name: ______________________________________________________ Date of Birth: ____________________________

Last First Middle

Allergy/Drug Allergy: Side Effect/Reaction:

1.

2.

3.

4.

☐ NO KNOWN DRUG ALLERGIES

Medical History Do you now or have you ever had:

☐ NONE OF THE CONDITIONS LISTED BELOW

☐ Aneurysm

☐ Atrial

Fibrillation/Flutter

☐ Convulsions

☐ Heart Attack

☐ HIV or AIDS

☐ TB (Tuberculosis)

☐ Abnormal Heart

Rhythm

☐ Acid reflux

☐ Arthritis

☐ Asthma

☐ Blood Disorder

☐ Cancer

☐ Cataracts

☐ Chronic Lung

Disease/COPD

☐ Clotting Disorder

☐ Congestive Heart

Failure

☐ Diabetes (Insulin? Y / N)

☐ Gallstones

☐ Gastrointestinal Disease

☐ Gout

☐ Headaches

☐ Heart Murmur

☐ Heart Valve Disease

☐ Hepatitis

☐ High Blood Pressure

☐ High Cholesterol

☐ Kidney Disease

☐ Kidney Stones

☐ Liver Disease

☐ Prostate Problems

☐ Rheumatic fever

☐ Sleep Apnea

☐ Stroke of TIA

☐ Thyroid Disease

☐ Ulcers

☐ Other

_______________________

Current Medications: Please include non-prescription medications, over the counter & vitamins or supplements:

Name of Drug Dose (include strength & quantity per day)

1.

2.

3.

4.

5.

☐ NOT TAKING MEDICATIONS

Page 3: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

HEALTH INFORMATION

Revised 1/8/2018

Pain and Nutrition:

Are you experiencing in Pain? ☐ NO ☐ YES

If YES, please rate your pain on a scale of 1 to 10 with 10 being the most painful: _____________

In the past 3 months, have you had a change in appetite? ☐ NO ☐ YES

In the past 3 months, have you had a change in weight of 10 or more pounds? ☐ NO ☐ YES

In the past month, have you experienced problems with swallowing? ☐ NO ☐ YES

Treatment History: (i.e. Previous Psychiatric/Medical Hospitalizations and/or other psychiatric treatment programs) Dates:

1.

2.

3.

4.

☐ NO PREVIOUS PSYCHIATRIC TREATMENT

Date of Last Physical Exam _____________________________________________________________________________________________

Primary Medical Provider (if not Family Centers Health Care)_________________________________________________________________

Address: ___________________________________________________________ Phone__(______)__________________________________

Primary Dental Provider: (if not Family Centers Health Care)__________________________________________________________________

Address: ___________________________________________________________ Phone_(______)____________________________________

Preferred Pharmacy____________________________________________________________________________________________________

Address: ___________________________________________________________ Phone__(______)__________________________________

Page 4: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

Client's Rights and Responsibilities

The client and the provider have a responsibility to each other to assure that the best possible service is provided and

appropriately used.

Each Client Has the Right to the Following:

• Considerate and respectful service.

• Service provided by qualified personnel.

• A reasonable response to his/her request for service and reasonable continuity of care.

• Service without discrimination as to race, religion, sex, gender identity/expression, national origin, sexual orientation,

ancestry, age, familial status, physical or mental disability or handicap, or ability to pay.

• To participate in the development of his/her treatment plan.

• To accept or reject any treatment plan.

• Family Centers Inc.'s policies such as eligibility for service, regulations, hours of service and fee information.

• Assistance in locating the appropriate service when continuity can not be provided

• To examine and receive an explanation of his/her bill for service, regardless of the payment source.

• To receive a copy of the Client's Rights and Responsibilities at the time service begins.

• To the name, title and professional credentials of any person providing or supervising his/her service.

• To review their case record in accordance with Family Centers Inc.'s policy.

It is the Client's Responsibility to:

• Accept or refuse any service.

• Direct grievances, concerns and recommendations for change to assigned staff member/supervisor and/or Program

Director

• Direct unresolved health, safety or quality-of-care concerns to The Joint Commission located at One Renaissance Blvd.,

Oakbrook Terrace, IL, 60181 and telephone number 630-792-5000.

• Keep all scheduled appointments or give 24-hour notice of cancellation.

• To inform clinician of changes in financial circumstances which may affect the fee.

In Order to Protect Your Privacy:

The Clinical Staff of Family Centers Inc. are required by law and professional ethics to maintain client confidentiality.

This is done within the context of standard agency practice. Your records are confidential and will not be

released or discussed with anyone outside of Family Centers Inc. without your written consent except as otherwise

provided by law.

Emergency/Crisis:

In the event there is an emergency or crisis outside of the agency’s business hours, (Monday - Thursday, 9 AM to 9

PM and Friday, 9 AM - 5 PM) please dial 877-349-4689 or go to your nearest hospital emergency department.

Minor Child:

The Clinical Staff of Family Centers Inc. are required to discuss and determine parental arrangements and responsibilities

for the client’s arrival and departure; procedures followed in the event of a medical emergency; inform the parent or

guardian of the clinic’s mandated reporting responsibility according to Section 17a-101 of the CT General Statutes.

The parent or guardian of a minor will sign for the child that they and the child have received and reviewed

the Client’s Rights and Responsibilities and have been explained these rights in an understandable and age

appropriate manner.

I have received and reviewed the Client's Rights and Responsibilities and I have been oriented to the

agency's policies and procedures and consent to treatment.

Client Signature___________________________________________ Date_______________________

Staff Signature ____________________________________________ Date_______________________

Page 5: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

CONSENT TO TREAT / BILLING

1. I (patient name) give permission for Family Centers Health Care to give me medical/dental/mental health treatments.

2. I authorize Family Centers Health Care to file for insurance benefits to pay for the care I receive.

I understand that:

• Family Centers Health Care will have to send my medical/dental/mental health records information to my insurance company.

• My share is due at the time of service. • I must pay for the cost of these services if my insurance does not pay or I do not have

insurance. 3. I understand:

• I have the right to refuse any procedure or treatment. • I have the right to discuss all medical/dental/mental health treatments with my provider. • If I miss or cancel within 24 hours (Friday’s by 12pm for Monday’s appointments) 2 or

more times, I may be unable to schedule any further appointments in advance.

Patient’s Signature Date Parent or Guardian Signature Date (for children under 18) Print name Date __________________________________________ __________________ Witness Date

Page 6: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

Family Centers Inc.

Notice of Privacy Practices Effective September 23, 2013

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access

to this information. Please review it carefully.

SUMMARY

Your Rights You have the right to:

• Get a copy of your paper or electronic medical record

• Correct your paper or electronic medical record

• Request confidential communication

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

Your Choices You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition

• Provide disaster relief

• Include you in a hospital directory

• Provide mental health care

• Market our services and sell your information

• Raise funds

Our Uses and Disclosures We may use and share your information as we:

• Treat you

• Run our organization

• Bill for your services

• Help with public health and safety issues

• Do research

• Comply with the law

• Work with a medical examiner or funeral director

• Address workers’ compensation, law enforcement, and other government

requests

• Respond to lawsuits and legal actions

Page 7: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

Family Centers Inc.

Notice of Privacy Practices Effective September 23, 2013

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of

our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information

we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request.

We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us

how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a

different address.

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that

information for the purpose of payment or our operations with your health insurer. We will say “yes”

unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to

the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations,

and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for

free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.

We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person

can exercise your rights and make choices about your health information.

Page 8: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

Family Centers Inc.

Notice of Privacy Practices Effective September 23, 2013

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on the

last page.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by

sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or

visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference

for how we share your information in the situations described below, talk to us. Tell us what you want us to do,

and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share

your information if we believe it is in your best interest. We may also share your information when needed to

lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Page 9: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

Family Centers Inc.

Notice of Privacy Practices Effective September 23, 2013

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when

necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public

good, such as public health and research. We have to meet many conditions in the law before we can share your

information for these purposes. For more information see:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We may use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of

Health and Human Services if it wants to see that we’re complying with federal privacy law.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual

dies.

Address workers’ compensation, law enforcement, and other government requests

Page 10: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

Family Centers Inc.

Notice of Privacy Practices Effective September 23, 2013

We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a

subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of

your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in

writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change

your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Special Rules Regarding Disclosure of Mental Health, Substance Abuse and HIV-Related Information

For disclosures concerning protected health information relating to care for mental health conditions,

substance abuse or HIV-related testing and treatment, special restrictions may apply. For example, we

generally may not disclose this specially protected information in response to a subpoena, warrant or other

legal process unless you sign a special Authorization or a court orders the disclosure.

Mental Health Information. Certain mental health information may be disclosed for treatment, payment and health care operations as permitted or required by law. Otherwise, we will only disclose such information pursuant to an authorization, court order or as otherwise required by law. For example, all communications between you and a psychologist, psychiatrist or social worker will be privileged and confidential in accordance with Connecticut and Federal law.

Substance abuse treatment information. If you are treated in a specialized substance abuse program, your permission will be needed for certain disclosures, but not emergencies, certain reporting requirements and other disclosures specifically allowed under Federal law.

HIV-related information. We will disclose HIV-related information as permitted or required by Connecticut law. For example your HIV-related protected health information, if any, may be disclosed in the event of a significant exposure to HIV-infection to personnel of Family Centers Inc., another person, or a known partner. Any use and disclosure for such purposes will be to someone able to reduce the outcome of the exposure and limited in accordance with Connecticut and Federal law.

Minors. We will comply with Connecticut law when using or disclosing protected health information of minors. For example, if you are an un-emancipated minor consenting to a health care service related to

Page 11: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

Family Centers Inc.

Notice of Privacy Practices Effective September 23, 2013

HIV/AIDS, venereal disease, abortion, or alcohol/drug dependence, and you have not requested that another person be treated as a personal representative, you may have the authority to consent to the use and disclosure of your health information.

Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new

notice will be available upon request, in our office, and on our web site.

If you have any questions about this Notice or would like further information concerning your privacy rights,

please contact

Family Centers Inc.

Robert Short, HIPAA Privacy Officer

P.O. Box 7550 Greenwich, CT 06830

[email protected]

203 869-4848

Page 12: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

Family Centers Inc.

Notice of Privacy Practices Effective September 23, 2013

Consent and Acknowledgment Form

I consent to the use or disclosure of my protected health information by Family Centers Inc. to any person

or organization for the purposes of carrying out treatment, obtaining payment or conducting certain healthcare

operations. I understand that further information regarding how Family Centers Inc. will use and disclose my

information can be found in Family Centers Inc.’s Notice of Privacy Practices.

By signing below, I understand and acknowledge the following:

I have read and understand this consent; and

I have received Family Centers Inc.‘s Notice of Privacy Practices currently in effect.

_____________________________________________

Print Name of Individual or Personal Representative

______________________________________________________________

_ Signature of Individual or Personal Representative

If signed by the individual’s representative, describe the legal authority of the representative to act on

behalf of the individual: ______________________________

Unable to obtain written consent and acknowledgment because:

□ Individual refused

□ Emergency treatment situation

□ Individual not able to sign due to incompetence or other medical reason

□ Other: ______________________________________

Date

________________________________

Page 13: Patient Information Form Date - Family Centers · Do you need a Translator: ☐ Yes ☐ No Are you a veteran of one of the United ... ☐ Kidney Disease ☐ Kidney Stones ... guardian

ADULT LDI

Intake__ Discharge__

Client Name:_________________________ Date:__________

This scale is intended to estimate your current level of distress with each of the eighteen areas of

your life listed below. Please circle one of the numbers (1-7) beside each area. Numbers toward

the left end of seven-unit scale indicate higher levels of distress, while numbers toward the right

end of the scale indicate lower levels of distress. Try to concentrate on how distress you

currently feel about each area.

7 = THE MOST DISTRESS I’VE EVER FELT

6 = EXTREMELY DISTRESSED

5 = VERY DISTRESSED

4 = MODERATELY DISTRESSED

3 = SOMEWHAT DISTRESSED

2 = VERY LITTLE DISTRESS

1 = NO DISTRESS

PLEASE CHECK ONE NUMBER FOR EACH ITEM AND TOTAL

MARRIAGE 7 6 5 4 3 2 1 SEX 7 6 5 4 3 2 1 RELATIONSHIP TO SPOUSE/SIGNIFICANT OTHER 7 6 5 4 3 2 1 RELATIONSHIP TO CHILDREN 7 6 5 4 3 2 1 RELATIONSHIP TO OTHER RELATIVES 7 6 5 4 3 2 1 HOUSEHOLD MANAGEMENT 7 6 5 4 3 2 1 FINANCIAL SITUATION 7 6 5 4 3 2 1 EMPLOYMENT/JOB 7 6 5 4 3 2 1 EDUCATION/SCHOOL 7 6 5 4 3 2 1 RECREATION/LEISURE 7 6 5 4 3 2 1 SOCIAL LIFE 7 6 5 4 3 2 1 RELIGION 7 6 5 4 3 2 1 MANAGEMENT OF TIME 7 6 5 4 3 2 1 PHYSICAL HEALTH 7 6 5 4 3 2 1 PERSONAL INDEPENDENCE 7 6 5 4 3 2 1 ROLE OF ALCOHOL or DRUGS IN THE HOME 7 6 5 4 3 2 1 SATISFACTION WITH LIFE 7 6 5 4 3 2 1 EXPECTATIONS FOR THE FUTURE 7 6 5 4 3 2 1 TOTAL: