ALCOHOL DRUG EVALUATION PREPARATION
|
|
|
- Erika Alexander
- 5 years ago
- Views:
Transcription
1 Alcohol/Drug Evaluation The alcohol drug evaluation is critical to the success of your case. We want you to get the best evaluation possible with the least amount of treatment, or classes, necessary. In order to receive the best and most accurate result you must be prepared and aware of the questions you will be asked. The following are the keys to obtaining a fair and good evaluation. Further, please read the attached questions as these questions, in some form, will be asked during the evaluation. Additionally, please read all handouts related to the alcohol/drug evaluation that we have provided you. Remember, if you want a diagnosis that states you have no alcohol/drug problem, you must reflect that you do not and have never had such a problem. As always, if you have any questions prior to the evaluation please contact me directly. *IF YOU ARE DOING THE DEFERRED PROSECUTION PROGRAM, PLEASE CONTACT ME DIRECTLY PRIOR TO YOUR ALCOHOL EVALUATION. KEYS TO A SUCCESSFUL ALCOHOL EVALUATION 1. No family history of dependence 2. First alcohol drug experience after the age of 15 years 3. Never had a dependence problem 4. Drink no more than twice/week 5. Drink no more than 2 drinks/time 6. You must explain why the events of your DUI are unusual 7. No alcohol/drug related criminal history 8. BAC under
2 The alcohol evaluation will consist of a self-reporting questionnaire, largely consisting of questions from the MAST (alcohol) Test and DAST (drug) Test. Here are the two tests please read prior to your evaluation. Michigan Alcohol Screening Test (MAST) Developed in 1971, the Michigan Alcohol Screening Test (MAST) is one of the oldest and, according to "experts," most accurate alcohol screening tests available, effective in identifying dependent drinkers with up to 98 percent accuracy. Questions on the MAST test relate to the patient's self-appraisal of social, vocational, and family problems frequently associated with heavy drinking. The test was developed to screen for alcohol problems in the general population. The following is the 22-question, self-administered MAST. The MAST Test The MAST Test is a simple, self-scoring test that helps assess if you have a drinking problem. Answer yes or no to the following questions: 1. Do you feel you are a normal drinker? ("normal" is defined as drinking as much or less than most other people) 2. Have you ever awakened the morning after drinking the night before and found that you could not remember a part of the evening? 3. Does any near relative or close friend ever worry or complain about your drinking? 4. Can you stop drinking without difficulty after one or two drinks? 5. Do you ever feel guilty about your drinking? 6. Have you ever attended a meeting of Alcoholics Anonymous (AA)? 7. Have you ever gotten into physical fights when drinking? 8. Has drinking ever created problems between you and a near relative or close friend? 9. Has any family member or close friend gone to anyone for help about your drinking? 10. Have you ever lost friends because of your drinking? 11. Have you ever gotten into trouble at work because of drinking? 12. Have you ever lost a job because of drinking? 13. Have you ever neglected your obligations, family, or work for two or more days in a row because you were drinking? 2
3 14. Do you drink before noon fairly often? 15. Have you ever been told you have liver trouble, such as cirrhosis? 16. After heavy drinking, have you ever had delirium tremens (DT), severe shaking, visual or auditory (hearing) hallucinations? 17. Have you ever gone to anyone for help about your drinking? 18. Have you ever been hospitalized because of drinking? 19. Has your drinking ever resulted in your being hospitalized in a psychiatric ward? 20. Have you ever gone to any doctor, social worker, clergyman, or mental health clinic for help with any emotional problem in which drinking was part of the problem? 21. Have you been arrested more than once for driving under the influence of alcohol? 22. Have you ever been arrested, or detained by an official for a few hours, because of other behavior while drinking? Scoring the MAST Test Score one point if you answered "no" to the following questions: 1 or 4. Score one point if you answered "yes" to the following questions: 2, 3, 5 through 22. A total score of six or more indicates hazardous drinking or alcohol dependence and further evaluation by a healthcare professional is recommended. 3
4 The Drug Abuse Screening Test (DAST) The Drug Abuse Screening Test (DAST) was developed in 1982 and is still an excellent screening tool. It is a 28- item self-report scale that consists of items that parallel those of the Michigan Alcoholism Screening Test (MAST). The DAST has exhibited valid psychometric properties and has been found to be a sensitive screening instrument for the abuse of drugs other than alcohol. Directions: The following questions concern information about your involvement with drugs. Drug abuse refers to (1) the use of prescribed or over-the-counter drugs in excess of the directions, and (2) any non-medical use of drugs. Consider the past year (12 months) and carefully read each statement. Then 1. Have you used drugs other than those required for medical reasons? 2. Have you abused prescription drugs? 3. Do you abuse more than one drug at a time? 4. Can you get through the week without using drugs (other than those required for medical reasons)? 5. Are you always able to stop using drugs when you want to? 6. Do you abuse drugs on a continuous basis? 7. Do you try to limit your drug use to certain situations? 8. Have you had blackouts or flashbacks as a result of drug use? 9. Do you ever feel bad about your drug abuse? 10. Does your spouse (or parents) ever complain about your involvement with drugs? 11. Do your friends or relatives know or suspect you abuse drugs? 12. Has drug abuse ever created problems between you and your spouse? 13. Has any family member ever sought help for problems related to your drug use? 14. Have you ever lost friends because of your use of drugs? 15. Have you ever neglected your family or missed work because of your use ofdrugs? 4
5 16. Have you ever been in trouble at work because of drug abuse? 17. Have you ever lost a job because of drug abuse? 18. Have you gotten into fights when under the influence of drugs? 19. Have you ever been arrested because of unusual behavior while under the influence of drugs? 20. Have you ever been arrested for driving while under the influence of drugs? 21. Have you engaged in illegal activities in order to obtain drug? 22. Have you ever been arrested for possession of illegal drugs? 23. Have you ever experienced withdrawal symptoms as a result of heavy drug intake? 24. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? 25. Have you ever gone to anyone for help for a drug problem? 26. Have you ever been in a hospital for medical problems related to your drug use? 27. Have you ever been involved in a treatment program specifically related to drug use? 28. Have you been treated as an outpatient for problems related to drug abuse? Scoring and interpretation: A score of 1 is given for each YES response, except for items 4, 5, and 7, for which a NO response is given a score of 1. Based on data from a heterogeneous psychiatric patient population, cutoff scores of 6 through 11 are considered to be optimal for screening for substance use disorders. Using a cutoff score of 6 has been found to provide excellent sensitivity for identifying patients with substance use disorders as well as satisfactory specificity (i.e., identification of patients who do not have substance use disorders). Using a cutoff score of <11 somewhat reduces the sensitivity for identifying patients with substance use disorders, but more accurately identifies the patients who do not have a substance use disorders. Over 12 is definitely a substance abuse problem. In a heterogeneous psychiatric patient population, most items have been shown to correlate at least moderately well with the total scale scores. The items that correlate poorly with the total scale scores appear to be items 4, 7, 16, 20, and 22. 5
KAP Keys. For Clinicians. Based on TIP 24 A Guide to Substance Abuse Services for Primary Care Clinicians. CSAT s Knowledge Application Program
KAP KEYS Based on TIP 24 A Guide to Substance Abuse Services for Primary Care CSAT s Knowledge Application Program KAP Keys For Based on TIP 24 A Guide to Substance Abuse Services for Primary Care U.S.
Pocket Card SBIRT Side 1 and 2
Pocket Card SBIRT Side 1 and 2 Pocket Card SBIRT Health Effects of Substance Abuse Alcohol Use Disorders Identification test (AUDIT) NAME: Date: The following questions concern information about your alcohol
SBIRT Screening and Brief Assessment Questionnaires
SBIRT Screening and Brief Assessment Questionnaires 1. Brief Screens: NIAAA quantity and frequency Single alcohol screening question) Single drug screening question Conjoint screening questions 2. Full
If you do not have health insurance, the initial appointment will be $232. Follow-up appointments will be $104.
APPLICATION FOR ADMISSION TO ADDICTION MEDICINE PROGRAM AT MARQUETTE GENERAL BEHAVIORAL HEALTH SERVICES FOR BUPRENORPHINE (Suboxone) THERAPY In order to be considered for admission to the Addiction Medicine
ALCOHOL/DRUG ASSESSMENT FORM
ALCOHOL/DRUG ASSESSMENT FORM DEMOGRAPHIC INFORMATION Date Client s Name Age Date of Birth Address How long have you lived at this address? Type of residence (Apt. Home, Duplex, Etc.) Rent? Own? With whom
Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol
PRE-EVALUATION FORM Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol High Blood Pressure Obesity Heart Defect
OTTAWA BOOTH CENTRE ADDICTIONS SERVICES APPLICATION PACKAGE PHYSICAL HEALTH
Note to Applicants Please complete all aspects of the Addictions Services Application Package. Applications that are incomplete cannot be processed. Please note that if you wish to attend the Anchorage
BASIC INFORMATION. Street Address (including city) Phone Number Can we leave messages? YES
Note to Applicants Please complete all aspects of the Addictions Services Application Package. Applications that are incomplete cannot be processed. Please note that if you wish to attend the Anchorage
BEHAVIORAL HEALTH SCREENING TOOLS
BEHAVIORAL HEALTH SCREENING TOOLS FOR THE CO-LOCATION OF BEHAVIORAL HEALTH SERVICES IN A PRIMARY CARESETTING Date: August 29, 2017 Introduction Today s Presenter Jacqueline Delmont, MD, MBA Delmont Healthcare
Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA Phone:
1 Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA 31525 Phone: 912-230-2436 drtara@driftwoodpsych.com Client name Date ADULT HISTORY FORM Presenting problems Why I came for counseling:
Screening Tools: Alcohol and Other Drugs
APPENDIX 1 Screening Tools: Alcohol and Other Drugs Short Michigan Alcoholism Screening Test (SMAST)... 49 Michigan Alcoholism Screening Test (MAST)... 50 Various Alcohol and Other Drug Screening Questions...
We admitted that we were powerless over alcohol that our lives had become unmanageable.
Step One We admitted that we were powerless over alcohol that our lives had become unmanageable. Alcoholics Anonymous (AA) (2001, p. 59) Before beginning this exercise, please read Step One in Twelve Steps
We admitted that we were powerless over alcohol that our lives had become unmanageable. Alcoholics Anonymous (AA) (2001, p. 59)
Step One 22 istockphoto.com/qingwa We admitted that we were powerless over alcohol that our lives had become unmanageable. Alcoholics Anonymous (AA) (2001, p. 59) Before beginning this exercise, please
P.I. PRESENTATION OUTLINE
A. Introduce yourself as a Member of A.A. and State Reason for the Visit: To carry the message of Alcoholics Anonymous, and describe what it is and what it is not. B. Post Phone Number and Web Pages of:
ADS. 10. There have been times when I have been jealous or resentful of others.
ADS Instructions The questions in this questionnaire are numbered. Match the number of the question with the number on your answer sheet. All questions should be answered on your answer sheet. Skipped
Chapter 7. Screening and Assessment
Chapter 7 Screening and Assessment Screening And Assessment Starting the dialogue and begin relationship Each are sizing each other up Information gathering Listening to their story Asking the questions
Client Contact Information. Name Date of Birth Soc Sec # Address City Zip. Home Phone Cell Phone Work Phone
Client Contact Information Name Date of Birth Soc Sec # Address City Zip Home Phone Cell Phone Work Phone May I leave messages on your home phone? Yes No work phone? Yes No cell phone? Yes No May I text
ADULT HISTORY QUESTIONNAIRE
ADULT HISTORY QUESTIONNAIRE Date: Full Name: Date of Birth: If applicable, please complete the following: Partner s Name: Partner s Age: Partner s Occupation: IF YOU HAVE CHILDREN PLEASE LIST THEIR NAMES
SUBSTANCE ABUSE ASSESSMENT FORM
SUBSTANCE ABUSE ASSESSMENT FORM Please make copies as needed and please type or print legibly. Instructions for use: Complete this form and use these questions to guide the EAP client interview when conducting
LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK Date. Personal History Information
1 LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK 74074 405-707-9600 Date Personal History Information Client's Name Referred By Address Phone City/State/Zip Birthdate Age Occupation Employed by Social
ADULT HEALTH HISTORY AND SYMPTOM QUESTIONNAIRE
ADULT HEALTH HISTORY AND SYMPTOM QUESTIONNAIRE Last Name: First Name: (The following information will help your therapist and/or psychiatrist guide your treatment and make recommendations.) I. MEDICAL
Weighing the Pros and Cons
Weighing the Pros and Cons Reasons to keep drinking the way I have been Reasons to cut down or quit From Controlling Your Drinking (nd ed.). Copyright 3 by The Guilford Press. Permission to photocopy this
Screening, Identification, Counseling, and Treatment of Opioid Use Disorder
Screening, Identification, Counseling, and Treatment of Opioid Use Disorder Joji Suzuki, MD Assistant Professor of Psychiatry, Harvard Medical School Director, Division of Addiction Psychiatry, Brigham
CHEMICAL USE EVALUATION INTERVIEW. A. Demographics
CHEMICAL USE EVALUATION INTERVIEW DATE OF EVALUATION A. Demographics COMPANY NAME: NAME ADDRESS PHONE: MARITAL STATUS SOCIAL SECURITY # DATE OF BIRTH AGE GENDER RACE/ETHNICITY VALID DRIVER S LICENSE: YES:
CHEMICAL DEPENDENCY EVALUATION INTERVIEW. A. Demographics
CHEMICAL DEPENDENCY EVALUATION INTERVIEW DATE OF EVALUATION A. Demographics COMPANY NAME: NAME ADDRESS PHONE: MARITAL STATUS SOCIAL SECURITY # DATE OF BIRTH AGE GENDER RACE/ETHNICITY VALID DRIVER S LICENSE:
Chapter 7. Screening and Assessment
Chapter 7 Screening and Assessment Screening And Assessment Starting the dialogue and begin relationship Each are sizing each other up Information gathering Listening to their story Asking the questions
The Council for Disability Awareness
Alcohol and Your Health It's a fact: alcohol is a prevalent part of our social lives. We unwind by drinking a beer or two at the game or having a glass of wine with dinner. We toast holidays and special
5975 Parkway North Blvd., Suite D 3060 Royal Blvd. South, Suite 110 Cumming, GA Alpharetta, GA 30022
1 5975 Parkway North Blvd., Suite D 3060 Royal Blvd. South, Suite 110 Cumming, GA 30040 Alpharetta, GA 30022 (p) 404-388-3909 www.focusforwardcc.com (f) 678-712-1945 info@focusforwardcc.com ADULT HISTORY
FIRST STEP WORKSHEETS
FIRST STEP WORKSHEETS These worksheets are not officially produced or approved by Alcoholics Anonymous. You can get the latest revision at http://www.royy.com. hr 11/03/02 SUGGESTION "The Steps shall set
Underwriting the Habits Risk of Alcohol Use Gregory Ferrara New York Life Underwriting January, 2013
Underwriting the Habits Risk of Alcohol Use Gregory Ferrara New York Life Underwriting January, 2013 The Company You Keep 1 Antitrust 2 New York Life adheres to the letter and spirit of the antitrust laws.
RESULTS OF THE DRUG ABUSE MONITORING SURVEY WITHIN CORRECTIONAL FACILITIES IN BERMUDA
Regional Workshop on Drug Information Networks (DINs) RESULTS OF THE DRUG ABUSE MONITORING SURVEY WITHIN CORRECTIONAL FACILITIES IN BERMUDA Antigua & Barbuda 2 nd August, 2012 Dr. Kyla Raynor Senior Research
COLUMBUS PSYCHOLOGICAL ASSOCIATES, L.L.P.
COLUMBUS PSYCHOLOGICAL ASSOCIATES, L.L.P. 2325 BROOKSTONE CENTRE PARKWAY / COLUMBUS, GA 31904 PHONE: (706) 653-6841 FAX: (706) 653-7843 Adult Outpatient Psychosocial History Psychosocial Self-Assessment
Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
Patient Questionnaire Name: Date: D.O.B.: Age: Referred By: Presenting Problem A. What are the main concerns or problems that brought you here today? B. Problem Checklist: please circle all that apply:
DAST: Drug Abuse Screening Test
DAST: Drug Abuse Screening Test These questions refer to the 12 months prior to today. Place this sheet in front of the offender and read the information aloud as you work through it together. Circle one
DESCRIPTION OF FOLLOW-UP SAMPLE AT INTAKE SECTION TWO
SECTION TWO DESCRIPTION OF FOLLOW-UP SAMPLE AT INTAKE 7 2.1 DEMOGRAPHIC CHARACTERISTICS Table 2.1 presents demographic descriptive data at intake for those who were included in the follow-up study. Data
New Client Questionnaire: (rev. 08/2016)
New Client Questionnaire: (rev. 08/2016) Client Name: Date of Birth: / / Date of First Session: / / What events or concerns brought you to my office? What goals would you like to accomplish? Are there
PATIENT IDENTIFICATION: Name: First Appointment Date: Birth Date: Address: City State Zip Home Phone #: Work #: Cell #: REFERRAL SOURCE: Referred By:
Andrew E. Leifer, M.D., P.C. 1202 Bergen Parkway, Suite 211 Evergreen, Colorado 80439 General Adult Psychiatry Outpatient and Hospital Care Medical Consultation-Liaison Service Telephone (303) 674-6074
Nebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
Nebraska Bariatric Medicine 8207 rthwoods Dr., Suite 101 Lincoln, NE 68505 MEDICAL HISTORY Name Today s Date The following page allows you to complete what we call a weight timeline. This is a very valuable
2016 Indiana College Substance Use. Survey SAMPLE UNIVERSITY
2016 Indiana College Substance Use Survey SAMPLE UNIVERSITY Results of the Indiana College Substance Use Survey 2016 Sample University Indiana Prevention Resource Center 501 N. Morton St., Suite 110 Bloomington,
EVEN IF YOU KNOW ABOUT DRINKING OR DRUGS. Simple Questions. Straight Answers.
EVEN IF YOU KNOW ABOUT DRINKING OR DRUGS Simple Questions. Straight Answers. WHY IS MY HEALTHCARE PROVIDER ASKING ME ABOUT ALCOHOL AND OTHER DRUGS? Asking these questions is part of good health care, just
MINDFUL WELLNESS CENTER, PLLC
PATIENT HISTORY NAME DATE PLEASE TAKE YOUR TIME AND COMPLETE THE ENTIRE FORM. You may use the back if needed for more explanation. Identifying Information: Date of Birth: Age: Sex: Place of Birth: Religion:
Welcome to the second module of the Screening, Brief Intervention, and Referral to Treatment Core Curriculum. In this module, we ll address screening
Welcome to the second module of the Screening, Brief Intervention, and Referral to Treatment Core Curriculum. In this module, we ll address screening patients for substance use in a clinical setting. 1
Implementation of the UNCOPE Universal Screen in Oklahoma
Implementation of the UNCOPE Universal Screen in Oklahoma March 2011 Prepared by Tom McDonald, Ph.D. Jody Brook, Ph.D. MSW/LCSW Yueqi Yan, M.A. The University of Kansas School of Social Welfare Lawrence,
A.A. I am responsible. P-36
Is A.A. for Me? Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from
APPLICATION FOR ADMISSION
The Women s Home, Inc. P.O. Box 7412, Arlington, VA 22207-9998 703/237-2822; Fax: 703/237-1167 e-mail: womenshm@aol.com; Web site: www.thewomenshome.com APPLICATION FOR ADMISSION Name: SSN: Birth Date:
What is a Drink? I only had one drink. One 12oz Beer One Single Shot 1.5oz One 4-5oz Glass of Wine
I only had one drink. What is a Drink? Several people say that they only had one drink or they only had three. The truth is, their one drink might really be two or three drinks in one. Below is the definition
ADULT INTAKE FORM. Name
Welcome to Solace Counseling Associates. Please note that the information is important for your care. Please fill out forms as completely as possible and have them ready before your first counseling session.
BAPTIST HEALTH SCHOOL OF NURSING NSG 3036A: PSYCHIATRIC-MENTAL HEALTH
BAPTIST HEALTH SCHOOL OF NURSING NSG 3036A: PSYCHIATRIC-MENTAL HEALTH THERAPEUTIC INTERVENTION AND RESOURCE MANAGEMENT: SUBSTANCE RELATED DISORDERS: CO-DEPENDENCY AND THE IMPAIRED NURSE LECTURE OBJECTIVES:
Taking an alcohol history
Taking an alcohol history Dr Tony Rao Consultant Old Age Psychiatrist, SLAM NHS Foundation Trust Visiting Researcher, Institute of Psychiatry, Neurology and Neuroscience Alcohol related brain damage Alcohol
Chapter 10. Alcohol Is a Drug
Section 1 Alcohol Affects the Body Alcohol Is a Drug Alcohol is the drug found in beer, wine, and liquor that causes intoxication. Intoxication includes all the physical and mental changes produced by
CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
CLIENT HISTORY CLIENT LEGAL NAME: DATE: CLIENT PREFERRED NAME: FAMILY & SOCIAL BACKGROUND Please list and describe your current family members (immediate, extended, adopted, etc.) and/or other members
Adolescent Sleep Disorder Questionnaire For Children Ages PATIENT NAME: (Please print clearly) Patient s Date of Birth: Age: Male Female
(PATIENT) Adolescent Sleep Disorder Questionnaire For Children Ages 12-17 Instructions: Please review this form for accuracy prior to submission. You may complete this information prior to arrival at the
Wasted AN INTRODUCTION TO SUBSTANCE ABUSE
Wasted AN INTRODUCTION TO SUBSTANCE ABUSE Dr. Brian L. Bethel Child and Family Therapist Independent Trainer and Consultant LPCC-S, LCDC III, RPT-S www.brianlbethel.com INTERPLAY COUNSELING & CONSULTING
MINOR CLIENT HISTORY
MINOR CLIENT HISTORY CLIENT NAME: DATE: FAMILY & SOCIAL BACKGROUND: Please list and describe your child s or teen s current family members (immediate, extended, adopted, etc.) NAME RELATIONSHIP AGE OCCUPATION
Cincinnati Christian University Drug and Alcohol Prevention Program
Cincinnati Christian University Drug and Alcohol Prevention Program Standards of Conduct for Employees & Students Employees It is a violation of University policy to use or be under the influence of alcohol
IT S OUR BUSINESS. Is drinking, using drugs. work? A L C O H O L D R U G S and G A M B L I N G
IT S OUR BUSINESS Is drinking, using drugs or gambling affecting my work? A L C O H O L D R U G S and G A M B L I N G in the Workplace I S I T A F F E C T I N G M Y W O R K? 3 Are you concerned that your
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005 INTAKE FORM Name: Date: Gender: Female Male Date of birth: Address: Home phone: Cell: Okay to leave a message? Yes No Email: Emergency
Welcome to the Centre for Aging and Wellness at Florida Hospital!
133 Benmore Dr. Winter Park, FL 32789 PH: 407-599-6060 FAX: 407-646-7747 Welcome to the Centre for Aging and Wellness at Florida Hospital! We are pleased you have chosen us as part of your health care
Screening, Brief Intervention, and Referral to Treatment (SBIRT) Part I: Introduction & Screening
Screening, Brief Intervention, and Referral to Treatment (SBIRT) Part I: Introduction & Screening Farah Khorassani, PharmD, BCPS, BCPP Shannon Tellier, PharmD Objectives Describe SBIRT rationale and screening
Session 2: Alcohol and Recovery 2-1
Session 2: Alcohol and Recovery 2-1 Alcohol in the Brain Alcohol upsets a delicate balance between chemical systems that stimulate and chemical systems that inhibit functions of the brain and body. Matrix
Heron Ridge Associates, PLC PARTNER RELATIONAL PERSONAL HISTORY INFORMATION. Client s Last Name First Name M.I. Street Address Date of Birth Age
Case #: Readmit? Yes No Heron Ridge Associates, PLC PARTNER RELATIONAL PERSONAL HISTORY INFORMATION PLEASE PRINT CLEARLY Today s Date: Client s Last Name First Name M.I. Street Address Date of Birth Age
Applicant s Name (PRINT): Applicant s Signature: Date: Anticipated Admission Date: Time: Staff Approval: Date:
FREEDOM SUBSTANCE ABUSE TREATMENT APPLICATION/REQUIREMENTS for ADMISSION PURPOSE: Our primary goal is to facilitate a stable environment that gives individuals an opportunity to break the cycle of homelessness
New Patient Questionnaire
New Patient Questionnaire Date of appointment (MM/DD/YYY): Name (Last, First, MI): Previous Names: DOB (MM/DD/YYY): Phone: Cell: Email: May we email you with sensitive information, such as test results?
Step One for Gamblers
Step One for Gamblers We admitted we were powerless over gambling that our lives had become unmanageable. Gamblers Anonymous (GA) (1989b, p. 38) Before beginning this exercise, please read Step One in
Client Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:
Client Intake Form Thank you for taking the time to openly and honestly answer the questions below. Your genuine responses are appreciated, as all information provided will assist your therapist to better
CENTRAL NEW YORK SERVICES DUAL RECOVERY PROGRAM BIO-PSYCHO-SOCIAL ASSESSMENT. Name: DOB: SSN: Race: Sex: Marital Status: # of Children:
CENTRAL NEW YORK SERVICES DUAL RECOVERY PROGRAM BIO-PSYCHO-SOCIAL ASSESSMENT Date of Intake: Therapist: I. IDENTIFYING INFORMATION Name: DOB: SSN: Address: Race: Sex: Marital Status: # of Children: Living
Sleep History Questionnaire. Sleep Disorders Center Duke University Medical Center. General Information. Age: Sex: F M (select one)
Sleep History Questionnaire Sleep Disorders Center Duke University Medical Center Part I: General Information Name: Address: Date: Phone: Age: Sex: F M (select one) Education (years of school): Occupation:
DRUG AND ALCOHOL QUESTIONNAIRE
DRUG AND ALCOHOL QUESTIONNAIRE Part I. Substance Abuse History Ever Used? Ever a Problem? Age of 1 st Use When last used? Alcohol Yes No Yes No Barbiturates or Yes No Yes No other sleeping pills Benzodiazepines
Chapter 10 Section 1 Notes
Chapter 10 Section 1 Notes Alcohol Is a Drug Alcohol is the drug found in beer, wine, and liquor that causes intoxication. Intoxication includes all the physical and mental changes produced by drinking
BIOPSYCHOSOCIAL SCREENING ADULT
BIOPSYCHOSOCIAL SCREENING ADULT CHART NUMBER: DOB: 1. IDENTIFYING INFORMATION Client Name: Availability: Family Member Name: Availability: Family Member Phone Numbers: Telephone (Day): Telephone (Eve):
Specialized terms used in this workbook and their meanings:
Glossary Specialized terms used in this workbook and their meanings: Absorption: The way alcohol enters the bloodstream. Alcohol is absorbed into the blood through the stomach and small intestine. Addiction:
DRUG-FREE UNIVERSITY COMMUNITY AND WORKPLACE
DRUG-FREE UNIVERSITY COMMUNITY AND WORKPLACE Overview The purpose of this statement is to comply with the federal Safe and Drug-Free Schools and Communities Act Amendment of 1989 and the Drug-Free Workplace
Screening for Substance Use in Clinical Settings
Screening for Substance Use in Clinical Settings Screening, Brief Intervention, and Referral to Treatment (SBIRT) Core Curriculum The University of Iowa Goals for Today Understand universal screening Identify
Intake Questionnaire For New Adult Patients
Intake Questionnaire For New Adult Patients This brief questionnaire will help me get to know you better in order to provide the best possible care for you. Please answer as honestly and completely as
12. I can be easily annoyed and angered while driving. 13. I am concerned about my drug use. 14. I have used my cell phone while driving.
OK DRI-2 Instructions We realize this is a difficult time for you. Nevertheless, we need more information so we can better understand your situation. All questions in this questionnaire should be answered.
Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx
Adult Information Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx 76092 817-614-1488 Dx code: Welcome to Restore Counseling Center. In order for us to gain a better understand of
Associates of Behavioral Health Northwest CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT
CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT Name: Date: I. PRESENTING PROBLEM What events or stressors led you to seek therapy at this time? Check all that apply. Mood difficulties (i.e. sad or depressed
San Diego Center for the Treatment of Mood Disorders 1
San Diego Center for the Treatment of Mood Disorders 1 DATE NAME Last Middle First REFERRAL HISTORY: How did you find us (via a referral, web search, recommendation)? Please provide the name and phone
Clinical Evaluation: Assessment Goals
Clinical Evaluation: Assessment Goals 1. Define Assessment Process 2. Identify Assessment Instruments 3. Define DSM-5 criteria for Substance Abuse and Dependence, specifiers and multi-axial assessment
ALCOHOLISM GETTING THE FACTS FACT SHEET 06. Visit: alcoholandyouni.com
FACT SHEET 06 ALCOHOLISM GETTING THE FACTS Most of us think we know something about alcoholism and drug addiction. After all, there are stories about addiction on TV and in the newspapers almost every
ADD/ADHD Patient Intake Form. Patients age 18 years or older
Lisa Sachdev, D.O. ADD/ADHD Patient Intake Form Patients age 18 years or older Please fill out the following questionnaire prior to your first appointment. You must be completely honest and detailed in
SLEEP QUESTIONNAIRE. Name: Sex: Age: Date: DOB: / / SSN: - - Address: Referring Physician: Family Physician: Height: Weight: Neck Size: Phone:
SLEEP QUESTIONNAIRE Name: Sex: Age: Date: DOB: / / SSN: - - Address: Referring Physician: Family Physician: Height: Weight: Neck Size: Phone: Please fill in the blanks, and check appropriate areas on the
PRISM SECTION 15 - STRESSFUL EVENTS
START TIME : PRISM SECTION 15 - STRESSFUL EVENTS Statement I.1: These next questions are about difficult or stressful things that can happen to people. It may be hard to remember everything about these
OFFICIAL POLICY. Policy Statement
OFFICIAL POLICY 9.1.6 Employee Drug and Alcohol Abuse Policy 2/8/16 Policy Statement Employee Drug and Alcohol Abuse Policy #CofC.HR.DA.03 Revised 12/2001 The Drug-Free Schools and Communities Act The
*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
BIOPSYCHOSOCIAL ASSESSMENT 224-008B page 1 of 5 / 06-14 Please complete this questionnaire and give it to your counselor on your first visit. This information will help your clinician gain an understanding
WHY THE ASI SHOULD BE REPLACED AND WHY MANDATES FOR ITS USE SHOULD BE ELIMINATED
WHY THE ASI SHOULD BE REPLACED AND WHY MANDATES FOR ITS USE SHOULD BE ELIMINATED The ASI (Addiction Severity Index) was initially designed as a program evaluation tool for VA populations and subsequently
Ethics and. Diagnosis. John Lisy. Executive Director - Shaker Heights Youth Center Treasurer NAADAC LICDC-CS, OCPS II, LISW-S, & LPCC-S
Ethics and Diagnosis John Lisy Executive Director - Shaker Heights Youth Center Treasurer NAADAC LICDC-CS, OCPS II, LISW-S, & LPCC-S 1 Goal of the presentation The goal of this presentation is to provide
Prescription Drug Abuse
Prescription Drug Abuse What is Prescription Drug Abuse (PDA)? Historically the use of prescription drugs was for nonmedical purposes. Today PDA is considered practicing medicine without a license. Self
Polysubstance Abuse Part 1. Introduction
Most people print off a copy of the post test and circle the answers as they read through the materials. Then, you can log in, go to "My Account" and under "Courses I Need to Take" click on the blue "Enter
Patient History & Sleep Questionnaire
Patient History & Sleep Questionnaire Patient Full Name: Nick Name: Birth date: Age: Sex: Height: Current Weight: Weight Five Years Ago: Peak Lifetime Weight: Marital Status: Single Married Divorced Widowed
Medicare Wellness Visit
of Birth: Today s : Medicare Wellness Visit Dear Patient, Your Medicare benefits include an Annual Wellness Visit to assist in preventing illness or detect illness at an early stage. Your Annual Wellness
PERSONAL HISTORY QUESTIONNAIRE
PERSONAL HISTORY QUESTIONNAIRE Here are several pages of questions that we want you to answer about yourself. Please answer them to the best of your ability, as completely and honestly as you can. Completing
Narrative Report - ASI-MV Addiction Severity Index - Multimedia Version
Site: Inflexxion Address: 320 Needham St., Newton MA 02464 Summary of Results for: Narrative Report - ASI-MV Addiction Severity Index - Multimedia Version Client Name: John Doe Client ID: 987654MM Client
PERSONAL HISTORY NAME TODAY S DATE LAST FIRST MI LIST ANY ADDITIONAL NAMES USED: ADDRESS PHONE (STREET) (CITY) (STATE) (COUNTY) (ZIP)
PERSONAL HISTORY PERSONAL INFORMATION: NAME TODAY S DATE LAST FIRST MI LIST ANY ADDITIONAL NAMES USED: ADDRESS_ PHONE (STREET) (CITY) (STATE) (COUNTY) (ZIP) AGE: DATE OF BIRTH: SOCIAL SECURITY #: RACE:
CSAT s Knowledge Application Program. KAP Keys. For Clinicians
Screening and Assessing Adolescents for Substance Use Disorders and Treatment of Adolescents With Substance Use Disorders CSAT s Knowledge Application Program KAP Keys For Clinicians Based on TIP 31 Screening
Sleep Insomnia Severity Index (SISI) Pittsburgh Sleep Quality Inventory. POMS Vigor subscale
Physical GLOBAL HEALTH PROMIS completed already Sleep PROMIS-Sleep Sleep Insomnia Severity Index () Pittsburgh Sleep Quality Inventory 8 items 7 items 18 items Vigor Vigor subscale 6 items 1 Sleep- PROMIS
Alcohol Addiction. Peer Pressure. Handling Social Pressures. Peer Pressure 2/15/2012. Alcohol's Effect on One s Health and Future.
Peer Pressure Handling Social Pressures Chapter 3 Peer Pressure is the influence of friends who are in your age group. It can influence the way you dress, your taste in music, and even in the way you walk
MO DRI-2 Instructions We realize this is a difficult time for you. Nevertheless, we need more information so we can better understand your situation.
MO DRI-2 Instructions We realize this is a difficult time for you. Nevertheless, we need more information so we can better understand your situation. All questions in this questionnaire should be answered.
CMBHS Help Desk:
Enrollment Document Number (Auto generated by CMBHS system) Enrollment Date Funding Source HHSC RSS LBHA MM/DD/YYYY Other Funding Source CHILDREN How many children are living with someone else due to a
Prepared by: Dr. Elizabeth Woodward, University of Toronto Resident in Psychiatry
Prepared by: Dr. Elizabeth Woodward, University of Toronto Resident in Psychiatry In broad terms, substance use disorders occur when a substance is used in a compulsive manner with a lack of control over