Intake / Assessment Form

Client Name: Date of Birth: Age: _______

Street/P.O. Box: Soc. Sec. No. ______________________

City, State:	Telephone:	_______________

In case of emergency who can we call? ________________________________________

Relationship to you: ______________________________ Phone #:

Who referred you?

Phone #: __________________________

What Providers do you have currently (PCP, Psychiatrist, Psychologist, Caseworker, Probation Officer, etc.)

Name & Phone #____________________________________________________________________

Name & Phone #____________________________________________________________________

Name & Phone #____________________________________________________________________

Name & Phone #____________________________________________________________________

Reviewing Counselor: __________________________________________ Date: ________________

EMPLOYMENT STATUS / EDUCATIONAL / VOCATIONAL HISTORY:

Current Employer	How long employed?

What do you do? ____________________________________________________________________

If Unemployed, How Long	Reason you left your last job?

Prior Work Experience:

1) How long did you work?	_______________________

2) How long did you work? ________________________

Ever Fired If Yes, Why? _______________________________________________

Ever Demoted If Yes, Why? ______________________________________________

Current Work Phone #	May we contact you at work? Yes No

Has your alcohol/drug use affected your employment at any time? If yes, how? ________________

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Comments_________________________________________________________________________

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High school attended?

Where was it? _________________When was it? _____	__________________________

Highest grade level achieved? ; Any additional educational experience?

If so, when and where? ______________________________________________________________

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Any special work skills? If so, what are they? _____________________________________________

Are there any vocational needs we can help you with? ______________________________________

Did you have any problems in school? If so what were they? _________________________________

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Was your alcohol or other drug use ever a problem in school? If yes, how? _____________________

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Were any emotional or behavioral issues ever a problem in school? If yes, how? _________________

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How are your reading skills?	Good	Fair	Poor

How are your writing skills?	Good	Fair	Poor

Disciplinary History:

Comments: ________________________________________________________________________

LEGAL HISTORY

Do you have any current legal problems? If so, what are they?

Pending Court Dates:

Attorney_________________________Phone _________________

Probation Officer_______Phone _________________

Previous Charges/Convictions (OUI’s, Assaults, etc.) If so what were they and when were they?

Did alcohol/drug use influence your legal issues? If so, how? ________________________________

__________________________________________________________________________________

Additional Comments:

MILITARY HISTORY:

Branch: ____ Total Length of Service: ____

Highest Rank:	_______ Combat: Yes No; Type of Discharge: _

Date OF DISCHARGE: _ Disabled: Yes _ No

Disciplinary History:

VA Benefits:

Was alcohol/drug use ever a problem for you in the military? If yes, how? _____________________
__________________________________________________________________________________

Were there any mental health issues as a result of your military service? If so, please briefly describe _________________________________________________________________________________

SUBSTANCE ABUSE HISTORY:

Please fill in the information for the type of substance you have used now or in the past.

Type of SubstanceAge of 1st useDate of last useHow often did you use?How much did you use?

Alcohol

Marijuana

Cocaine

Heroin/other opiates

Speed/stimulants

Sedatives/Tranquilizer

Hallucinogens

SUBSTANCE ABUSE HISTORY (Continued):

Inhalants

Nicotine

Other

Comments

Have you ever experienced any of the following problems as a result of your use of lack of use?

Please check all that apply:

Black Outs	Shakes	Nervousness	Problems with Sleep

Seizures	Diarrhea	Cramps	Guilt	Depressed Mood

Have you ever used IV drugs? Yes ____ No ____ If YES, when was the last time?

Have you tried to cut down, control, or stop your use before? Yes ____ No ____

Do you think about using often? Yes ____ No ____

Have others thought you may have a problem with your use? Yes ____ No ____; If YES who, explain why they thought you may have a problem?

Do you think your use makes matters worse? Yes _____; No ______;

If YES, please explain why

List previous treatment for substance abuse treatment/counseling:

Treatment Provider/Clinician	Dates	Response to Treatment

(including length of abstinence before relapse)

_________________________________________________________________________________

Have you ever been to: AA ___ NA ___ CA ___ ACOA ___ ALANON ___ ALATEEN ___

Other Most Recent Sponsor Yes No

Comments:

________________________________________________

MENTAL HEALTH HISTORY

List previous treatment/counseling for mental health issues:

Treatment Provider/Clinician	Dates	Comments

Have you ever had thoughts or attempts of physically hurting or killing yourself? _______________

If so: When	What Happened

When	What Happened

What was upsetting you that led to this?

Did your family or friends understand and respond to your concerns or problems?

If this applies, please explain:

Do you feel like hurting yourself now? Yes _____; No _____;

Have you ever had thoughts of hurting others? If yes please explain:

Do you have any history of the following? Please check all that apply:

Anxiety _____ Depressed mood _______ Mood swings _____ Irritability ______

Feeling scared a lot _____ Panic ______ Angry ______ Guilty _____ Isolating ______ Lonely _____

Hearing voices when no one is around ______ Seeing things that may not be there _____

Comments:

FAMILY PSYCHIATRIC/CHEMICAL DEPENDENCY HISTORY:

Have there ever been any significant psychiatric/chemical dependency problems with family members? Yes _____; No _____; If yes, who and when? Please explain:	__

ABUSE/TRAUMA HISTORY:

Have you ever been hurt emotionally by family or others in the past or currently?	Yes No

Have you ever been sexually mistreated by family or others in the past or currently?	Yes No

Have you ever been hurt physically by family or others in the past or currently?	Yes No

Have you ever witnessed violence as a child or adult?	__ Yes __ No

If yes to any of the above please describe:

Other Significant Trauma/Losses:

SOCIAL FUNCTIONING:

What is your current living situation like?

How long have you lived there?

Who are your closest friends?

____________________________________________________________________________

Do they have problems with alcohol or other drugs? Yes ______ No ______ Are they supportive of your seeking help? Yes _____ No _____

Has your alcohol/drug use affected your social relationships in a negative way? If yes, please explain ____________________________________________________________________________________________________________________________________________________________________

Has your emotional or behavioral issues affected your social relationships in a negative way? If yes, please explain _____________________________________________________________________

_________________________________________________________________________________

What are your interests or hobbies?

What do you do for fun?

Do you belong to any Professional/Social Organizations? If so, what?	____________________________________________________________________________

Describe your Religious/Spiritual Orientation (current and past):

How important are your Religious/Spiritual beliefs to you now? Please describe.

__________________________________________________________________________________

How is your financial situation? Please circle one. Excellent _____ Good _____ Fair ____ Poor ____

Comments:

List 3 personal strengths:

List 3 personal weaknesses:

Describe how you want life to be in two years:

What makes you feel good about yourself?

Describe a time or event when things went well:

Identify your cultural/ethnic heritage/identity:

Native American Afro American Hispanic Asian American Caucasian ___ Other

Are there any significant cultural characteristics that you think is important for us to know about or may affect your treatment? Yes _____ No _____ If YES, please explain:

MEDICAL HISTORY

Are there any current medical problems? If so, please describe: _____________________________

____________________________________________________________________________________________________________________________________________________________________

Do you have a current medical doctor? Yes____, No_____. If yes who? ________________________________________________________________________________

When did you see him or her last? ___________________________

When did you have your last physical and where? ______________________________

What is his/her phone number? ______________________________________________

Are there any current prescribed/non-prescribed medications that you use? If so, what are they and how often do you use them? __________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

Do you take them as directed? Yes _____ No _____

Do you have any physical needs that we need to be aware of? If yes, what are they? ____________________________________________________________________________________________________________________________________________________________________

Do you have any allergies? Yes _____ No _____ If YES, what are they?	_____________________

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How is your appetite currently? Average _____ Over Eat _____ Under Eat ____Purges

Has your appetite changed in the last 6 months and if so how? _______________________________

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Have you had any significant weight gain or loss within the last 6 months? If so, how much? _______

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Are you under a doctor’s care for any medical issues addressed on this form or other medical issues?

Yes ____ No ____ If YES, Please describe:

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