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(opisanie sytuacji spowodowanej nadu|ywaniem przez dan osob alkoholu - atmosfera w domu, zachowanie osoby i problemy z tego wynikajce, interwencje Policji, pobyt w Izbie WytrzezwieD ) Za zeznanie nieprawdy lub zatajenie prawdy przy skBadaniu zeznaD grozi kara pozbawienia wolno[ci do lat 3 ( art. 233 Kodeksu Karnego) Podstaw prawn zobowizania do leczenia odwykowego stanowi art. 24 do 36 ustawy z dnia 26 pazdziernika 1982r o wychowaniu w trzezwo[ci i przeciwdziaBaniu alkoholizmowi tekst jednolity (Dz.U. z 2019r poz.2277) Powy|sz procedur wdra|a si wobec osb ,ktre w zwizku z nadu|ywaniem alkoholu powoduj rozpad |ycia rodzinnego, demoralizacj nieletnich ,uchylanie si od zaspakajania potrzeb rodziny lub systematycznie zakBcaj spokj i porzdek publiczny. & & & & & & & & & & & & & & . podpis osoby skBadajcej wniosek ANKIETA DO WNIOSKU W SPRAWIE LECZENIA OSOBY Z PROBLEMEM ALKOHOLOWYM 1. Imi i nazwisko /osoby z problemem alkoholowym/...................................................................................... 2. Imiona rodzicw.............................................................................................................................................. 3. Data urodzenia................................................................ 4. PESEL ........................................................... 5. Adres zamieszkania........................................................................................................................................ 6. Adres do korespondencji................................................................................................................................ 7. WyksztaBcenie................................................................................................................................................ 8. Miejsce pracy...................................................................... nie pracuje od................................................... 9. Pomoc MOPS tak/nie jaka? ......................................................................................................................... ........................................................................................................................................................................... 10. Stan cywilny...............................................................rodzinny................................................................... 11. Osoby pozostajce we wsplnym gospodarstwie domowym: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & 12. Czy wywizuje si z obowizku utrzymania rodziny.................................................................................. 13. Pije alkohol: piwo/wino/wdka/inne............................................................................................................ 14. Od jak dawna nadu|ywa alkoholu............................................................................................................... 15. 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Jak zachowuje si w stanie nietrzezwym: spokojny, agresywny: sBownie/fizycznie, wywoBuje awantury, inne.............................................................................................................................................................. ............................................................................................................................................................................ 17. Czy byBy interwencje Policji........................................................................................................................ 18. Czy wobec kogokolwiek z rodziny (bliskich) sprawca problemu stosuje przemoc? ................................. je|eli tak, to wobec kogo .................................................................................................................................. przemoc fizyczna: kopanie, szarpanie, bicie ......................................................................................... przemoc psychiczna: obelgi, krzyk, zmuszanie do okre[lonych zachowaD,........................................ zaniedbywanie: .................................................................................................................................... czy Bo|y na utrzymanie: ........................................................................................................................ Czy zaBo|ono  Niebiesk Kart Przemocy w Rodzinie tak/nie Jak dBugo wystpuje przemoc w rodzinie: & & & & , czy w zwizku z wystpowaniem przemocy byBy zawiadamiane organy [cigania (Policja, Prokuratura, Sd) .......................................................................................................& & & & & & ........................................... 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