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IDENTIFYING INFORMATION
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What brings you here today?
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Accompanied (By Whom)
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Patient lives with whom explain
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Patient Sex
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Marital Status
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Physical Barriers to Treatment
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Physical Barriers Comments
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Specific Barriers to Treatment
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Specific Barriers Others
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Patient Other Services
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CURRENT PROVIDERS
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PCP
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Specialists
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Therapists (Self)
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Other
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PAST PSYCHIATRIC HISTORY
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Psychiatric History Includes
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Patient Hospitalized
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Patient Hospitalized When and Where
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Hospitalised
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Hospitalised Medications
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Family history of substance abuse
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Paternal Family substance/alcohol abuse
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Maternal Family substance/alcohol abuse
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Paternal Family Mem History of suicide
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Maternal Family Mem History of suicide
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Paternal Family history of Mental Illness
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Maternal Family history of Mental Illness
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CLIENT'S MEDICAL HISTORY
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Patient Current Medications
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Medical/Physical Problems
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Any other medical problem
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Patient's Disability
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Identify Disability
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Patient's Surgical Procedures
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Recent Tests, Labs (STD,illness)
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HISTORY OF WITHDRAWAL (Explain)
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Withdrawal Symptoms
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PATIENT FAMILY MEDICAL HISTORY
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Family Medical History (Paternal)
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Paternal describe other illness
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Family Medical History (Maternal)
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Maternal describe other illness
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Sleep
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Hard to fall asleep
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Sleep - How many hours
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Appetite/Dietary Habits
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Appetite/Dietary Habits Duration
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Appetite/Dietary Habits
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Appetite/Dietary Comments
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Appetite/Dietary
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Energy level
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Energy Level - Past 3 months
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Energy level - Usual
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Energy Level - Today
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CLIENT'S DEVELOPMENTAL HISTORY
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Client's Family Biological/Adopt
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Client Adopted Age
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Client's # of Siblings(Name(s)/A
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Client's Place of Birth
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Client's # of Moves in Lifetime
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Client Raised by (Parent)
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Client's Family Contact
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Client's Parents Married
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CLIENT'S SEXUAL HISTORY
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Sexual Orientation(s)
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Client's Sexual Status
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Practice Safe Sex
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Client First Sexual Encounter Ag
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Was this consensual
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Are you at risk for HIV
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Are you at risk for an STD or Hepatitis
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SPIRITUAL HISTORY
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Personal Spiritual/Cultural Belief System
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Spiritual Practices by Family
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Spiritual/Cultural Comments
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CLIENT'S MARRIAGE HISTORY
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Client Marriage History
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Client's Children (names and age
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EDUCATIONAL HISTORY
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Highest level of education
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Last School Attended and When
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Degrees, diplomas, certifications, specializations
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Learning Disabilities
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Learning Disabilities Comments
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Vocational, Trade, or other Schooling
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Vocational,Trade,other Schooling Comments
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MILITARY SERVICE
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Military Service
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Military Service Active Duty
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Military Service Branch
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Military - Date of Discharge
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Military - Type of Discharge
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VOCATIONAL HISTORY
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Current Employment
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Current Employment Explain
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Current Employment Duration
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Past Employment
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Past Employment Explain
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Past Employment Duration
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Reason for Leaving
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LEGAL HISTORY (Explain if Necess
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Ever Arrested
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Ever Convicted
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Current Legal Problems
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Describe - Current Legal Programs
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TRAUMA & ABUSE HISTORY
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Sexual
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Describe - Severity of Abuse
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Describe - Duration
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Physical
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Describe - Severity of Abuse
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Describe - Duration
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Emotional
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Describe - Severity of Abuse
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Describe - Duration
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Neglect
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Describe - Severity of Abuse
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Describe - Duration
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Ever been in an accident
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Seen someone injured or die
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Accident, Die or Injured Comments
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SUBSTANCE USE HISTORY
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Ever used drugs for recreation
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Do you now
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Do you drink caffeine beverages
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Caffeine Amount Daily
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Experienced Problems With
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Explain Experienced Problems
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Age drug use began
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Types of drug/s
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Drug - How often
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Drug - Most recent use
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Alcohol - Age at first use
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Alcohol - Most recent use
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Alcohol - How often and what amount
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Alcohol - How Admin
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Marijuana - Age at first use
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Marijuana - Most recent use
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Marijuana - How often and what amount
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Marijuana - How admin
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Cocaine/Crack - Age at first use
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Cocaine/Crack - Most recent use
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Cocaine/Crack - How often and what amount
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Cocaine/Crack - How admin
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Hallucinogen - Age at first use
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Hallucinogen - Most recent use
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Hallucinogen - How often and what amount
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Hallucinogen - How admin
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Heroin - Age at first use
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Heroin - Most recent use
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Heroin - How often and what amount
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Heroin - How admin
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Opioids - Age at first use
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Opioids - Most recent use
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Opioids - How often and what amount
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Opioids - How admin
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Meth - Age at first use
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Meth - Most recent use
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Meth - How often and what amount
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Meth - How admin
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Methamphetamines- Age-first use
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Methamphetamines-Most recent use
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Methamphetamines- How often and what amount
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Methamphetamines- How admin
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Prescription Amphetamines - Age at first use
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Rx Amphetamines - Most recent use
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Rx Amphetamines How often and what amount
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Rx Amphetamines - How admin
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Prescription meds (abuse)- Age-first use
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Prescription med (abuse)-Most recent use
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Prescription meds (abuse) - How often and what amount
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Prescription meds(abuse) - How admin
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Nicotine - Age at first use
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Nicotine - Most recent use
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Nicotine - How often and what amount
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Nicotine - How admin
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Other Abuse Comments
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increase in substance use over time
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explain
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unsuccessful controlling use
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explain
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a lot of time involved in substance use
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explain
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intense desire or craving to use
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explain
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obligations missed resulting from use
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explain
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social problems resulting from use
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explain
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social activities abandoned from use
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explain
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family activities abandoned from use
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explain
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continued use despite recurring problems
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explain
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CLIENT'S TREATMENT HISTORY
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Treatment for Addiction
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Reactions to Treatment Received
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Explain number of times in treatment
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most recent sobriety beginning/end date
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explain number attempts getting sober
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Types of treatment
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Experience with self-help groups
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Support Systems
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Have you ever attempted to stop using
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Support System Community,Family,Friends
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CLIENT’S MENTAL HEALTH STATUS
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Suicidal/homicidal
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Suicidal/homicidal
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Reliability
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Reliability-Clinician perception
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Appearance
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Client Appearance
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Client Appearance - Other
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Personal Hygiene
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Client Personal Hygiene
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Client personal hygiene other
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Clothing
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Client Clothing
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Clothing (Describe if striking)
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Behavior
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Client Behaviour
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Attitude
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Client Attitude
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Eye Contact
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Client - Eye Contact
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Speech
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Client Speech
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Psycho motor Activity
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Client - Psycho motor Activity
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Interaction during interview
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Client Interaction during interv
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Change during interview (describ
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Mood, Temperament & Emotional
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Client Mood
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Client Temperament
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Client Emotional
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Emotional Range
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Affect
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Client - Affect
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Perceptual disturbances
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Client - Perceptual disturbances
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Thought processes
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Client - Thought processes
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Content of thought
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Client Content of thought
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Information and intelligence
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Appropriate to age and education
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Orientation to
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Client Orientation to
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Memory
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Client Memory
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Coordination
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Client Coordination
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Judgment & Insight
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Client Judgment & Insight
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Able to follow instructions
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Able to concentrate
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CRISIS & RISK ASSESSMENT
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Crisis Assessment 1 -10
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Given Crisis Number
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Client Needs Crisis intervention
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Crisis plan necessary
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Risk to harm self
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Risk to harm to others
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Risk Assessment 1 (low)-10 (High
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Crisis & Risk Comments
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Client's Strengths
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Client's Challenges
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SUMMARY - Strengths
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SUMMARY - Challenges
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SUMMARY - Needs
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SUMMARY - Client issues
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Stages for Primary DX
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Motivation for treatment (explain)
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External motivation for treatment (explain)
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Internal motivation for treatment (explain)
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ASAM Dementions
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Dimension 1
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Dimension 1 (Narrative)
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Withdrawal Management
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Withdrawal management levels
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Dimension 2
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Dimension 2 (Narrative)
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Dimension 3
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Dimension 3 (Narrative)
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Dimension 4
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Dimension 4 (Narrative)
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Dimension 5
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Dimension 5 (Narrative)
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Dimension 6
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Dimension 6 (Narrative)
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SUMMARY - Recommendations
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Recommended Levels of Care
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Assessment Completed by:
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