Dr. Brown's Outline for Developing A Home Drug Abuse Program

What is the house's position on drug abuse?_{(Check all that apply)}

Absolutely no drugs or alcohol use allowed
Only occasional use of alcohol (eg. Social, Family, Religious Events)
Marijuana or opiate use for medical reasons (eg. Pain Management, Addiction Management )
Other

What is the Purpose of the Program?_{(Check all that apply)}

To prevent any family member from using illicit drugs
To prevent only the children from using ilicit drugs
To help addicted family members discharged from treatment to stay off drugs
Monitoring drug abuse for work
Monitoring drug abuse for court
Other

Persons Included?_{(Check all that apply)}

Everyone
Children Only
Specific Persons
House Guests
Spouse or Significant Other
Other

In which Program Components are Family members required to participate?_{(Check all that apply)}

Drug Free Pledge
Education - videos, books, articles, etc.
Drug Testing - scheduled, random, or for cause
Sign and Symptoms Scale Education

When will Test Specimen be Collected?

Unannounced
Once a month
Once a week
Random or for cause
No testing at this time
Other

What is your preferred source of outside help?_{(Check all that apply)}

Physician
Self Help Group
The Clergy
Mental Health Professional
Multidisciplinary
Other

What signs of drug abuse are present?_{(Check all that apply)}

Attire
Conduct
Manners
Attitude
Friends and Associations
School and Work performance
Hygiene
Health
Other