Intervention Specialist



iWitness

Thank you participating in getting your loved one help. A key component to helping is gathering together each participant’s eyewitness account. So please answer the following questions as completely as you are able. When you’re done, hit ‘submit’ and the information will be securely forwarded to our team.


Identified Loved One (ILO)
First Date
Contact Info
Your Name
Your Email
Cell Phone
Home Phone
Work Phone
Mailing Address
Relation to ILO
Relationship status with ILO
What You've Witnessed
Drug(s) of choice:
Prescription mediactions:
General health:
Smoker?  Yes No
If so, how much? Brand?
Past treatment/Therapy History:
Hurt self or others:
Police incident(s):
All arrests:
Parole:
Any pending court issues:
Time in jail:
All autos/self accidents:
Domestic violence:
Dangerous behavior:
Suicidal talk/attempts:
If so, when/where?
Weapon in home?
More details
Employment history:
Write down a brief description of the problem, from your vantage point.
List the costs you have seen as a result of the problem.
What family issues do you see?
What do you think will be his/her primary reservations be to accepting help?
To better understand the group dynamic, what issues are you dealing with
in your own life around addiction or behavior you want to change?
List the people whose voices matter the most in your loved one's life in order.