Psychosocial Assessment

Transcription

1 Florida Department of Corrections Substance Abuse Program Services Psychosocial Assessment General Information: Inmate Name: DC #: Age: Gender: Race: DOB: Last City of Residence: Length of Sentence: Referred by: Classification Reception Center Self Other Program: Intensive Outpatient Program Residential Therapeutic Community Substance Abuse Transitional Re-entry Program Location: Fill out all information as thoroughly as possible. Presenting Problem: Page 1 of 17

2 Alcohol and Drug History: Name of Drug Have Tried Maximum Use Daily Weekly Method of Use Alcohol Cocaine Crack Cocaine Marijuana Heroin *Other Opiates *Barbiturates *Amphetamines *Hallucinogens Inhalants PCP * Opiates include Codeine, Morphine * Barbiturates include Downers, Sedatives, Quaaludes * Amphetamines include Speed, Uppers * Hallucinogens include Acid, LSD, Mushroom Age Started Age Quit Drug of Choice (Check One per column) 1st 2nd 3rd 1. How did you support your drug/alcohol habit? (Check all that apply) prostitution stealing selling growing working family friends manufacturing 2. Do or have you ever used a needle to inject drugs? If yes, was injection: intramuscular intravenous skin popping Have you ever shared your needle or works? 3. Did you experience withdrawal symptoms when you first became drug free? If yes, check all that apply: crawling sensations under the skin hallucinations tremors cramping sweats Page 2 of 17

3 4. Where does your using generally take place? With whom? When? 5. Did you try to quit/limit your use of chemicals or change use of chemicals? If yes, why? 6. Did anyone pressure you to enter treatment? If yes, who? 7. I used chemicals to (check all that apply): make friends easily deal with anger feel in control work/study better be less critical of self feel adequate feel accepted by others relieve depression avoid things feel comfortable with sex feel more confident relax or unwind feel more alert forget anger feel happy feel more tolerant of others help me sleep other I used chemicals when I felt (check all that apply): happy guilty sad nervous bored hyper depressed tired lonely worried angry frustrated Medical History: 1. Do you have any of the following medical conditions at this time? (check all that apply) allergies head injury hepatitis back injury cirrhosis TB VD pregnancy HIV/AIDS knife wounds gunshot wounds other Page 3 of 17

4 Prior Treatment History: Treatment Code 1 Jail 2 Community Mental Health 3 Community Substance Abuse 4 Detox 5 Other Specify 1. List all past treatment experiences, including drug and alcohol, detox, mental health programs and hospitals. Year Treatment Code Reason for Treatment Months in Treatment Did You Complete? Page 4 of 17

5 Family History: 1. List below father, mother, brother, and sisters: Name Relationship Age Years of Education Occupation Living at Home? 1. Health, 2. Mental Health, 3. Drug/ Alcohol Problem ** Date of Death **Choose by number, all that apply. 2. Explain reason for death on any of the above: 3. Who did you live with while growing up? 4. Describe briefly how your family got along with each other: 5. When was your last contact with your parents? 6. Who do you feel closest to? Why? Page 5 of 17

6 7. List your spouse, significant other and children: Name Relationship Age Years of Education Occupation Living at Home? 1. Health 2. Mental Health 3. Drug/ Alcohol Problem** Date of Death **Choose by number, all that apply. 8. Explain reason for death on any of the above: 9. How many times have you been married? Abuse History: 1. How would you describe the discipline you received while growing up? Very Strict Moderate Inconsistent Permissive Abusive No Discipline At All 2. How were you punished as a child? 3. Were you ever abused as a child? If yes, Physically Verbally Sexually 4. Have you been abused since you have been an adult? If yes, explain: 5. Have you ever been accused of abusing your children? spouse or significant other? parents? If yes, please explain: Page 6 of 17

7 6. Do you think you have potential for abusing others? If yes, explain: Vocational/Educational History: 1. Fill in information for your last three jobs: Employer Type of Work Salary/Wage How Long? Reason for Leaving 2. Have you ever lost any jobs due to alcohol and drug use? If yes, how many? 3. Did you usually drink and/or use drugs while working? 4. What type of job would you like to have? 5. Describe any current financial problems or fears: 6. List Education: Level Grade Completed Average Grades Did You Have Behavior Problems? Elementary Junior High/Middle School High School College 7. Describe any difficulties you have in: Reading Writing Comprehension 8. Do you have any future education plans? If yes, explain: Page 7 of 17

8 Sexual History/HIV Assessment: 1. State your sexual preference: men women both 2. At what age did you have your first sexual experience? Describe: 3. Have you had more than one sexual partner in the past ten (10) years? If yes, check one (1) of the following: more than Have you ever been forced to have sex against your will? 5. Have you ever received money, drugs or alcohol for sex? 6. Have you ever had sexual relations while under the influence of drugs or alcohol? 7. Do you have, suspect you have, or have had any of these sexually transmitted diseases? (Check all that apply): Herpes Gonorrhea Syphilis HIV/AIDS Chlamydia Genital Warts 8. Have you ever been exposed to and/or tested (to your knowledge) for Tuberculosis (TB) or Hepatitis B? 9. To your knowledge, have you ever had sexual contact or shared needles with anyone who had AIDS or HIV infection (the AIDS virus) or who later developed AIDS or HIV infection? Yes No 10. Have you ever had, or are you now having, sexual relations with a person of the same sex as yourself? Yes No 11. Have you ever had sexual relations, to your Knowledge, with a man who has had sex with another man? Yes No Page 8 of 17

9 12. Have you engaged in: sex with a known/suspected bisexual? Yes sex with a known/suspected IV drug user? Yes sex with a prostitute? Yes Prostitution? Yes IV Drug Use Yes sex with 2 or more partners in a 12 month period? Yes 13. Have you ever received a blood transfusion for blood products since 1977? No No No No No No 14. Would you like to receive an HIV test? Legal History: 1. How many times have you been arrested? How many convictions? Any pending? Charge (list last 5 received) Convicted? Incarceration/Probation? (indicate type/length of time) Drug/Alcohol Related? 2. Do you think your criminal activity is related to your drug/alcohol use? How? Social/Leisure History: 1. How do you spend your leisure time (prior to incarceration and now?) 2. How would you like to spend leisure time? 3. How has alcohol and drugs affected leisure activities? Page 9 of 17

10 4. Do your friends drink and use drugs? Do you have any friends who are clean? Military History: 1. Have you ever served in the military? If yes, what branch? What was your highest rank? 2. If you served, when were you discharged? And how? Honorable Dishonorable Medical Bad Conduct Undesirable If other than honorable, please explain: Cultural/Spiritual History: 1. What was your religion while growing up? 2. How important was your religion in the past? Extremely Important Moderately Important Fairly Important Not At All Important 3. How important is your religion to you at the present? Extremely Important Moderately Important Fairly Important Not At All Important 4. Do you believe in a higher power? 5. Do you believe your cultural/ethnic background influences your chemical use? If yes, please explain: Page 10 of 17

11 Suicide History: 1. Have you ever seriously considered killing yourself? If yes, please explain: 2. Have you ever developed a plan? If yes, when? 3. Have you ever attempted to take your own life? If yes, complete below. Dates Method Attempted Under Influence? Treatment Received 4. Have you ever practiced self-mutilation? If yes, when? 5. Do you have violent tendencies? Under what circumstances? 6. Do you have current homicidal or suicidal thoughts? Please describe: Interest in Recovery: 1. Do you believe you have a serious problem? Yes No Maybe If yes or maybe, explain: If yes or maybe, do you believe that you need help for these problems? Yes No Maybe Page 11 of 17

12 2. Do you believe that other people (family, probation officer, etc.) feel that you have any serious problems? Yes No Maybe If yes or maybe, specify: 3. Do you believe that other people feel that you need help for these problems? Yes No Maybe 4. Is there anything about which we haven t asked you that you think we should know? Mental Status Exam: 1. Client s affect and mood: Describe: appropriate anxious angry euphoric flattened other depressed ( severe moderate mild) 2. Client s physical appearance: Describe: neat overweight poor hygiene disheveled underweight other 3. Client s speech: normal slow response loud voice soft voice slurred speech other Page 12 of 17

13 Describe: 4. Client was alert and oriented to: person time place situation Describe: 5. Client s insight: good denies problems blames others other Describe: 6. Client s judgment: intact impaired questionable poor impulse control Describe: 7. Does the client display any of the following? thought disorder memory loss ( short-term long-term both) hallucinations ( visual auditory both) psychosis delusions 8. Describe the client s general attitude and behavior (cooperative, hostile, manipulative, guarded, etc.) Page 13 of 17

14 Put an Inventory of Drug and Alcohol Use DSM IV x under the drug next to the statement that you answer Yes Section I 1. a. Approximate date you last used this substance? A L C O H O L M A R I J U A N A C O C A I N E O T H E R b. Quantity/Amount used? Section II 1. a. Have you found you need more of the substance to achieve the desired effect? (high, buzz) b. Have you found you have less effect when using the same amount? (i.e. Initially 2 beers or 2 joints made you high and now they don t.) 2. a. Have you developed problems when coming down after heavy usage of drugs or alcohol? (See list on page #2) b. Have you used the same substance or a closely relate don to avoid withdrawal symptoms? 3. a. Have you ever used larger amounts than you intended? b. Have you ever used for a longer period of time than you intended? 4. a. Have you ever had a persistent desire to use? (Strong craving) (Can you abstain from using the chemical or do you just put using off) b. Have you ever tried to cut down unsuccessfully? c. Have you ever tried to control your use or regulate your usage? 5. a. Have you spent a great deal of time in activities necessary to obtain substances? (Visiting several doctors or driving long distances, etc.) b. Have you spent a great deal of time using a substance? c. Have you spent a great deal of time recovering from effects of using a substance? (hangovers) 6. a. Have you ever given up an important family social, occupational, or recreational activity due to use? b. Have you ever reduced time spent involved in important social, occupational, recreational activities, or family events to recover from use? 7. Have you continued to use substances despite knowledge of psychological or physical problems? Page 14 of 17

15 Section III A M C O 1. Has recurrent substance use resulted in a failure to fulfill major role obligations at work, school, or home? (Repeated absences, poor performances, suspension or expulsion, neglect of family or job) 2. Have you recurrently used substances in situations in which it was physically hazardous? (Driving a car, operating a machine, etc.) 3. Has your recurrent use of a substance resulted in substance related legal problems? (i.e. arrests, probation violations) 4. Have you used despite persistent or recurring social or interpersonal problems caused by or exacerbated by substance use? (Arguing with spouse about use, physical fights?) Withdrawal Symptoms Experienced A. Nausea Circle any and all that apply to you. B. Vomiting C. Anxiety D. Tremors E. Increased Pulse Rate F. Sweating G. Seizures H. Hallucinations I. Fatigue J. Insomnia K. Vivid Unpleasant Dreams L. Hypertension M. Increased Appetite N. Increase Heart Beat O. Heart Palpitations P. Blurring of Vision Q. Psychomotor Agitation R. Dysphoric Mood S. Muscle Aches T. Psychomotor Retardation U. Fever V. Uncoordinated W. Diarrhea Alcohol with/without Physiological Dependence Remission: Cannabis with/without Physiological Dependence Remission: Cocaine with/without Physiological Dependence Remission: - Counselor s Response Only - Diagnostic Impression Other: (Specify) Alcohol Abuse Cannabis Abuse Cocaine Abuse Counselor Signature: Date: Page 15 of 17

16 Narrative Summary: (Include Client Strengths and Weaknesses and Impressions) Page 16 of 17

17 Treatment Recommendations: Use index number in identifying problem areas. 1. Substance Problem 4. Education 7. Social 2. Medical 5. Vocational 8. Family 3. Criminality 6. Behavior 9. Mental Health Index # Problem List: Index # Recommendations List: Counselor Signature/Credentials Date Supervisor Signature/Credentials Date Page 17 of 17