Intervention Assessment | Stillpoint Interventions

INTERVENTION ASSESSMENT

If you are reading this, you are likely exhausted. You’ve been living in the "chaos of the crash"—the constant worry, the broken promises, and the fear for your loved one’s future.

Taking this step is an act of profound love. An intervention isn't about confrontation; it is about creating a "still point" where the noise of addiction or mental health struggles stops, and the path to healing begins.

Why We Ask These Questions

This assessment is designed to help us build a roadmap specifically for your family. There are no "wrong" answers—only honest ones. By sharing these details, you allow us to:

Anticipate obstacles before they arise.
Identify the right level of care based on medical and behavioral needs.
Pre-verify insurance so we can present a concrete plan the moment your loved one says "yes."

Your Privacy is Our Priority

We understand the sensitive nature of your situation. All information shared here is strictly confidential and used solely by the Stillpoint team to prepare for your intervention.

Section 1: About You

Your Full Name

Your Relationship to [The Identified Loved One]: (e.g., Parent, Spouse, Sibling, Close Friend)

Primary Phone Number

Discretion Preference: Is it safe to leave a voicemail or text if you don't answer?

Yes, it is safe.

No, please wait for me to answer.

Best Time to Connect:

Morning

Afternoon

Evening

Email Address

Your Role: Are you the main person coordinating this intervention, or are you filling this out on behalf of a group?

Section 2: The Identified Loved One (ILO)

First name

Last name

Birthday

Month

Day

Year

Primary Concern: (e.g., Alcohol, Substance Use, Gambling, Eating Disorder, Mental Health)

Duration: How long has this been a primary concern?

Living Situation: Does the ILO live alone, with family, or is their housing unstable?

Section 3: Safety & Medical History

Medical Issues: Are there any known physical health conditions (e.g., liver issues, heart conditions, seizures)?

Mental Health: Has the ILO been diagnosed with any co-occurring disorders (Anxiety, Bipolar, PTSD)?

Risk of Harm: To your knowledge, has the ILO ever expressed suicidal ideation or exhibited violent behavior?

Withdrawal Risk: Does the ILO experience physical tremors or sickness when they stop using?

Section 4: Usage & Behavior Patterns

Frequency: Is the usage daily, binge-style, or constant?

Consequences: Please check all that apply:

Job loss or financial instability

Legal issues (DUI, arrests)

Relationship breakdowns

Neglect of children/dependents

The "Bottom": What was the specific event that led you to reach out to Stillpoint today?

Section 5: The Family System (The Intervention Team)

The Enabler: Who in the family currently provides financial support, housing, or "covers" for the ILO’s behavior?

The Point Person: Who is the ILO closest to or most likely to listen to?

Potential Conflict: Is there anyone who might actively sabotage the intervention or "leak" the plan to the ILO?

Section 6: Previous Attempts

Treatment History: Has the ILO been to detox, residential treatment, or IOP before? If so, where and for how long?

Barriers: Why do you believe previous attempts did not result in long-term recovery?

Section 7: Anticipated Barriers to Treatment

Anticipated Excuses: What is the ILO most likely to say when offered help? (e.g., "I can't leave my job," "Who will watch my dog?", "I’m not as bad as [Person X].")

Financial Constraints: Aside from insurance, are there specific concerns regarding the cost of care or travel?

Professional/Legal Obligations: Does the ILO have upcoming court dates, professional licenses at risk, or work contracts that they feel prevent them from leaving?

Family Resistance: Is there a specific family member who believes "they just need more willpower" rather than professional treatment?

Section 8: Insurance & Logistics

Primary Insurance Provider: (e.g., Blue Cross Blue Shield, Aetna, Cigna, etc.)

Member ID Number:

Policy Holder Name & Date of Birth: (If different from the ILO)

Type of Plan:

PPO (Typically allows for out-of-state/private options)

HMO (Typically requires local/in-network referrals)

Medicaid/Medicare

No Insurance (Self-Pay)