Birthday*

Position in Family*

Are/Were Your Parents Separated?*

Are/Were Your Parents Divorced?*

Is Either Parent Deceased?*

Are You Receiving Any Other Income? (Disabilities, Social Assissistance, etc.)*

Do You Have Any Money on Your Person? *

Do You Posses A Valid Driver's License?*

Have You Previously Attended a Rehabilitation Center?*

Have You Ever Attended AA or NA Meetings?*

Have You Ever Been Married?*

Are you Presently Married?*

Are you Widowed?

Did You Complete High School or have your GED?*

Any Post-Secondary Education?

Are You Currently Working?*

Have You Ever Been Fired From A Job Because Of Your Use Of Alcohol Or Drugs?*

Have You Ever Quit A Job Because Of Your Use Of Alcohol Or Drugs?*