Meaningful Person Questionnaire Name First Last Email PhonePatients Name First Last Relationship to PatientProgram*Adult InpatientYouth InpatientOutpatientCounselorChoose a Counselor HereAlicia EganAmanda ShayAmber CoutureAnne BurkettAnn GloeBonnie BeebeChloe GusterChris CartwrightChristine PryorColin RamseyDave BoblittDeAnna HarrisDeniele FlemingElizabeth BoelterIsaac McGahanJari HickmanJason SchillingJered CarterJessica BarnettLisa MooreLisa SevenerMaude NickoloffMeghan TraversMichael Lovett-StewartMichelle FlynnPatty NygaardRoseanne JohnsonSarah McCauleyTammra SandallToni FogliTreva HarmonTyler DouglasVicki GutheridgeAre you living with the patient at this time?YesNoHow has the relationship been affected?What changes would you like to see the patient make?How has the patient's employment/school been affected?What do you know about the patient's pattern of use?Have you made any attempts to make the patient stop using in the past?YesNoHow do they react when you try to discuss their substance use?Why do you think that the patient drinks/drugs?Below are some questions about your feelings and opinions related to your loved one's drinking or drug use.I feel frustratedVeryModeratelySlightlyNot at allPlease ExplainI feel guiltyVeryModeratelySlightlyNot at allPlease ExplainI feel afraidVeryModeratelySlightlyNot at allPlease ExplainI feel lonelyVeryModeratelySlightlyNot at allPlease ExplainI feel helplessVeryModeratelySlightlyNot at allPlease ExplainI am unable to discuss my problems with othersVeryModeratelySlightlyNot at allPlease ExplainI feel responsible for my loved one's use of chemicalsVeryModeratelySlightlyNot at allPlease ExplainMy emotional and physical health have been affectedVeryModeratelySlightlyNot at allPlease ExplainAnything else that you would like to tell us about the patient?