Internet Addiction Recovery Program APPLICATION ... - HEAL

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PARTICIPANT HISTORY (Continued) TRAUMA HISTORY (Check all that apply) Internet Addiction Recovery Program Anxious Hyper vigilant Nightmares Sleeplessness Phobias Prefers Isolation Depressed Shy/Withdrawn Dissociates Avoidant Headaches Stomachaches Under eating Over eating Binge eating Conduct Problems Peer problems Irritable/Angry Bullying Hyperactivity Low impulse control Violent behavior Running Away Lying Stealing Sexually acting out Low Self‐Esteem Lacks Empathy Distracted Homicidal Thoughts Participant is a survivor of Sexual assault Physical abuse Verbal abuse Emotional/Psychological Abuse Car Accident War/Veteran Serious Illness/Disability Divorce Multiple Relocations Loss of Home Natural Disaster Death in the Family Past history of suicide attempts Please describe ________________________________________________________ How many ___________ Does participant report feeling hopeless ___________________________________________________________________________________ STRESS List the types of stresses participant experiences (family, work, relationship, self, health etc.) ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ How does participant handle stress ______________________________________________________________________________ LEGAL HISTORY Is there a history of legal trouble If so, please describe _________________________________________________________________________ Has there been an arrest If so, for what ____________________________________________________________________________________ Participant is on probation. If so, what are the requirements _____________________________________________________________________ Have any other family members experienced legal problems If so, who and what __________________________________________________ EMPLOYMENT HISTORY Participant is currently employed. Employer’s name ___________________________________________________________________________ Job Title _________________________________________________ Length of employment _________________________________________ Participant has been terminated from a previous job. If so, describe ______________________________________________________________ RELATIONSHIPS Is participant involved in a romantic relationship Yes No Please list important people and friends in participant’s life: Name City State Phone Page | 6 reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 restart@netaddictionrecovery.com | www.netaddictionrecovery.com
Internet Addiction Recovery Program FAMILY INFORMATION Describe biological Father’s relationship with participant ____________________________________________________ __________________________________________________________________________________________________ Describe Step‐Father’s relationship with participant _______________________________________________________ _________________________________________________________________________________________________ Describe biological Mother’s relationship with participant __________________________________________________ _________________________________________________________________________________________________ Describe Step‐Mother’s relationship with participant ______________________________________________________ _________________________________________________________________________________________________ Which family member’s is participant closest to _________________________________________________________ Which family relationship is most strained ______________________________________________________________ Does participant have brothers or sisters □ No □ Yes Siblings‘ Names Age Current Grade Difficulties in learning or other disabilities (describe) Other significant information about this participant’s family What current problems exist in the family unit ____________________________________________________________ ___________________________________________________________________________________________________ Is the family experiencing in current/past stressors _________________________________________________________ ___________________________________________________________________________________________________ Please describe your family’s strengths ___________________________________________________________________ ___________________________________________________________________________________________________ Page | 7 reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 restart@netaddictionrecovery.com | www.netaddictionrecovery.com
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Internet Addiction Recovery Program APPLICATION ... - HEAL

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