Addictive Disorders Assessment Form

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Transcription:

Addictive Disorders Assessment Form Thorpe Recovery Centre Telephone: 780.875.8890 Fax: 780.875.2161 Email: info@thorperecoverycentre.org CLIENT INFORMATION First Name Middle Name Last Name Phone Number Alternate Phone Number Fax Number Email Address Street Address City Prov. Postal Code Gender: Marital Status Birthdate Current Age Provincial Health Care Number Ethnic Origin Occupation Employer EMERGENCY CONTACT INFO Name Relationship Street Address City Prov. Postal Code Phone Number Alternate Phone Number

REFERRAL Who was the referral source for this program? AHS (AADAC-AB) Employer E.A.P. Social Services Psychologist Physician ADS (SK) Mental Health Worker Other If Other, please specify. Referral Contact Referral Phone No. History Have you previously attended any services offered by Thorpe Recovery Centre? Yes No Unsure If yes, what services did you access. Detox Program Sex Addiction Chemical Dependency Gambling Program Outpatient Counseling Other Have you attended treatment anywhere else? Yes No Year attended treatment If yes, what services did you access. Detox Program Residential Program What treatment centre did you attend? Legal Status Do you have any charges pending, upcoming court dates, probation orders or past charges or other legal issues. If so, please explain: How has your alcohol and/or drug use or gambling affected your legal status?

GENERAL INFORMATION What do you plan to gain out of this program? Please be as specific as possible. Please indicate all substances that you have used. Substance Used Frequency of Use Daily Weekly Monthly Age of First Use Date of Last Use Is Use of this substance a problem? Substance Used Frequency of Use Daily Weekly Monthly Age of First Use Date of Last Use Is Use of this substance a problem? Substance Used Frequency of Use Daily Weekly Monthly Age of First Use Date of Last Use Is Use of this substance a problem? Substance Used Frequency of Use Daily Weekly Monthly Age of First Use Date of Last Use Is Use of this substance a problem?

What problems do you have directly related to your substance use? Please describe problems caused by your alcohol and/or drug addiction. Which of the following have you experienced as a result of your alcohol and/or drug use? Please check all that apply. Blackouts Inability to stop drinking or using once you start. Feelings of guilt. Increased tolerance of alcohol and/or drugs. Drinking or using in the morning. Previous attempts to stay sober or clean followed by a return to drinking or using. Hospitalization due to use of alcohol and/or drugs. Advised by a physician or other health professional to stop or reduce drinking or using. Which of these employment / school issues have you experienced in the past? Please check all that apply. Absenteeism Drinking or using drugs at work or school. Resigning from work or dropping out of school as a result of your alcohol and/or drug use. Disciplinary action Concerned about performance. Attending work or school under the influence of alcohol and/or drugs. Do you have any addiction concerns / problems other than alcohol, drugs and gambling? Example: smoking, co-dependency, eating disorders, workaholism, sex, internet etc. If Yes, please explain.

PSYCHOLOGICAL Have you ever experienced any of the following? Suicide Attempts Physically violent towards others. Verbally abusive towards others Thoughts of self harm or suicide. Extreme depression If any of the above have been experienced, please indicate the date, circumstances and the out come. Have you ever been diagnosed with a mental health problem? If Yes, please describe. Year Recreation What social and leisure activities are you currently involved in? Have you ever been affected by the alcohol and/or drug use or gambling of friends or family. If yes, please explain. How do you feel about socializing without alcohol and/or drugs or gambling? With whom do you spend most of your free time? Family Friends Alone Other If other, please explain.

Are you satisfied with spending your free time this way? Yes No Unsure How many close friends do you have? Are you satisfied with spending your free time this way? Yes No Unsure Is it easy for you to meet new friends? Yes No Unsure Spiritual Please explain your current understanding of spirituality. Family of Origin Describe your family life when you were growing up. Describe your relationship with your family (parents & siblings) today. What does your family think of your alcohol / drug and/or gambling abuse?

Current Relationships Please select your current relationship status. Single Married Common Law Seperated Divorced Widowed How long have you been in this relationship or non-relationship status? Please indicate number of years. Do you have any concerns regarding your relationship or non-relationship? Please explain. Do you have any children? Please list their names and ages: Do you have any concerns regarding your relationship with your children? Please describe your concerns? What does your spouse/partner/children think of your alcohol and/or drugs or gambling abuse? With whom are you now living? How long have you been living where you are now? Do you plan a move in the near future? Do you have sex with men? Do you have sex with women?

Have you been sexually abused? Have you ever been physically abused? Have you ever received counseling for these issues? Please explain. How has your alcohol and/or drug, or gambling abuse affected your relationships? What is the highest level of eduction you have completed? What is your current employment status? Do you have any financial difficulties? What is your usual occupation? What is your usual curent occupation? What is your current source of income? MEDICAL INFORMATION Current Doctor s Name Telephone No. Please list any medication that you are on as well as the dosage.

Please list any alergies that you may have. Please list any medical conditions that we need to be aware of. Please use this area to explain or expand upon any issue that you feel is relevant to your addiction.

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