|
Where did you find us?
|
Who referred you?
|
|
|
Therapists
• • •
|
|
Do you use online scheduling?
|
Want access to online portal?
|
|
Which specialists do you see?
• • •
|
Primary Care Physician
|
|
|
|
|
Substance abuse screening
|
|
|
Do you use substances in moderation?
|
Have you lost friends because of using?
|
|
have you ever experienced blackouts?
|
Has using lead to difficulty at work?
|
|
Difficult to stop drinking after 1-2 drinks?
|
Have you avoided obligations when using?
|
|
Family express concern about your using?
|
Have you avoided family because of using?
|
|
Friends express concern about your using?
|
Have you avoided kids because of using?
|
|
Do you ever feel guilty about using?
|
Have you missed work because of using?
|
|
Have you attended AA or NA?
|
Do you use before noon?
|
|
Have you ever got in fights when using?
|
Have you experience shaking after using?
|
|
Has using ever lead to relationship problems?
|
Have you ever been hospitalized after using?
|
|
Have you ever been told you have liver trouble?
|
Has use resulted in psychiatric hospitalization?
|
|
Have you ever got professional help for using?
|
Have you ever gotten a DUI?
|
|
Have you ever got religious help for using?
|
Have you ever been arrested because of using?
|
|
Any antidepressants?
|
Irritability or dramatic changes in behavior?
|
|
|
|
|
Has using been a problem before?
|
|
|
Comments
|
Recommendations
|
|
Completed by:
|
|
