ࡱ>    |F` bjbj yU  \ \ \ '''(*t Ɯ.5jb6b6?an$EGGGGGG$fhΠk\ [ak b6?f lb6\ ?EEy0 ,\ b6P . `q!l'i. 0Ɯ7JffDf\ IlkkujƜ 3    Department of Human Services (DHS) Division of Addiction Services (DAS) Information Systems Management (ISM) Unit Data Entry form on Paper for CPSAI Clients Client Pre-Screening/Pre-placement Assessment Module (ASI) BioPsychoSocial Interviewer Severity Index DSM-IV Evaluation Outcome (Please download and keep extra copies at all time in case of Internet Connection failure) NJSAMS Real-time Data System (Do not use training or demo. purposes)  HYPERLINK "https://njsams.rutgers.edu/samsmain/cpsaihome.htm" https://njsams.rutgers.edu/samsmain/cpsaihome.htm If you have any questions please call customer service at Phone: 609-292-3331; 609-943-5905; 609-292-1466 Email:  HYPERLINK "mailto:kyukyu.hlaing@dhs.state.nj.us" kyukyu.hlaing@dhs.state.nj.us or  HYPERLINK "mailto:njsamscustomerservice@dhs.state.nj.us" njsamscustomerservice@dhs.state.nj.us Updated: 11/13/2006 PRE-ADMISSION Client Information  Date of Pre-Admission: / / Requests/Pre-admit #: _____________ Interviewer/Staff Name: __________ __________ First Last Clients: _____________ __________ ____________ First name Middle name Last name Parent Name: ________________________________  Date of birth: / /  Social Security#: / / /  Gender (M/F/Transgender/Other): If other Specify: _______________  Are you Hispanic or Latino (Y/N) If Yes What Ethnic Group do you consider yourself? Central American Dominican Puerto Rican Cuban Mexican South American Other (Specify) ____________________________ What is your race? 1. Black or African American American Indian Native Hawaiian/other Pacific Islander Alaska Native Asian White Other (Specify) ________________________ Living Arrangement at Pre-Admission: Homeless-Shelter Homeless-Streets Dependent Living/Institution Independent Living  Contact Restrictions (Y/N): Explain: ________________ Primary Language: English Spanish Other If Other, Specify: ____________________________ Secondary Language: English Spanish Other If Other, Specify:_____________________________ In what country were you born?  CONTROL Forms.OptionButton.1 \s   CONTROL Forms.OptionButton.1 \s  If not born in US, How many years have you lived in the US years In what country was your mother born? 1. United States 2. Other In what country was your father born? 1. United States 2. Other Religious Preference:- 1. Protestant 2. Catholic 3. Jewish 4. Islamic 5. Other 6. None Who is the head of household? Self Spouse/Partner Parent Grandparent Other Relative Address: ____________________________________________ City, State, Zip ________________________________________ Phone #: (______) ______ - __________ Email: _________________________________ Is this residence own by you or your family? 1. Yes 2. No How did you hear about us? ___________________ Referral Source: 1. self; 2. family; 3. School; 4. Professional; 5. Child Protective Services; 6. Court; 7. Other If other; Specify ___________________ Contact (Family, Friends etc.): ______________________ Contact Phone: (______) ______ - __________ Case Manager/Agency: ___________________________ CM or Agency Phone: (_______) ________-_______________ PRE-ADMISSION Client Information Contd Add-on Page for CPSAI DYFS Cost Center Local Office: ___________________________ Region: Metro, North-Central, South County:__________ Case Name: ______________________ DYPS Worker Name and Phone: _____________________________ Supervisor Name and Phone: _______________________________ Call attempts to client for Assessment: First Attempt, Date:__________ Second Attempt, Date:___________ Home Visit, Date:_______________ Client came at which attempt: _______________________________ Priority Level: 1, 2 or 3 If assessment is not completed: Primary Reason:- (To be filled in after attempt to assessment only) 1 = Client cancellation 2 = Caseworker cancellation 3 = Client deceased 4 = Client homeless 5 = Client incarcerated 6 = Client missing 7 = Client no show 8 = Client out-of-county 9 = Client out-of-state 10=Client refusal 11=Unable to contact client (e.g., by phone) 12=Other Income Verification WFNJ CASH Assistance: Yes No Medicaid Number (if any): __________ TANF or GA (if any): ________________ Total members of household: ________ Total monthly income: ______________ Eligibility Status: Yes No (See Chart) NJSAMS ASSESSMENT (ASI) EMPLOYMENT/SUPPORT STATUS Counselor/Interviewer Name: _________________________________________  Assessment Date: / / Do you have a valid drivers license? No Yes Do you have an automobile available? No Yes What is the highest grade you completed in school? Do you have a high school diploma or GED No Yes Are you currently enrolled in school or a job training program? Not enrolled (If not enrolled answer the following if applicable..) 1.Dropped out 2.Expelled 3.Suspended 4.Medical Leave 5.Home Study 6.Other Enrolled Full Time Enrolled Part Time Other Which best describes your CURRENT employment situation? Full-time work or military (35 hours a week or more) Part-time (regular hours) Part-time (not regular hours) Student Home Maker Retired or Disabled Unemployed: Actively looking for work Unemployed: Not looking for work Unemployed: Volunteer work Living in an institution, like a jailor prison, hospital or overnight treatment program Does anyone contribute to the MAJORITY of your support in any way? (Like giving you money, food, housing) No Yes; if Yes; Who? 1. Spouse/Partner 2. Parent/Foster Parent 3. Brother/Sister 4. Grandparen 5. Other Relatives 6. Unrelated other Have you ever held a full-time job? No Yes If Yes, How long did you hold your longest full-time job? (Full-time = 35+ hours per week, not necessarily your most recent job.)   Years Months In the past 30 days, how many days were you paid for working? [Include under the table work, paid sick days and vacation. If worked a 5-day work- week, answer would be 20 days,] Usual or last Occupation:- 1. Higher Executives; Large Proprietor; Major Professionals 2. Business Mgrs, Medium Proprietor, Lesser Professionals 3. Admin. Personnel; Small or Minor Professionals 4. Clerical/Sales Workers; Technician 5. Skilled Manual Employees 6. Machine Operators; Semi-skilled 7. Unskilled Labor 8. Disabled 9. Welfare 10. None, No work History Do you have a profession, trade or skill? (Do you get training or go to school to learn skills you could put on a job application) No Yes During the past 6 months, did you receive any of the following public assistance? Temporary Aid to Needy Families TANF (welfare assistance for people with children) General Assistance GA (welfare assistance for people without children) SSI or Disability Insurance (Social Security Disability) Food Stamps or WIC Did not receive any Public Assistance In the past 6 months, how many months have you received any public assistance? months How much money did you receive from the following sources in the past 30 days?  Employment (Net take home pay, include any under the table money)  Unemployment compensation:  Public Assistance/TANF/General Welfare/SSI $  Retirement (Pension, Benefits or Social Security) $  Disability $  Illegal (Cash obtained from drug dealing, stealing, $ fencing stolen goods, illegal gambling, prostitution, etc.) What is your total annual family income before taxes include TANF and food stamp benefits (your earnings plus those of others who live with you)? $ How much money did you receive from the following sources in the? SourcesPast 30 days Past 31-60 days past 61-90 days SSI/SSD/SSA HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 Other benefits such as welfare, veteran's, worker's compensation HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 Food stamps  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 WIC HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 Assistance from family members to buy food, pay rent, get medical care or other HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 Rental assistance or subsidy such as Section 8, HUD or TAP HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 Pay from work, regular or part-time jobs. This does not include vocational rehabilitation or stipend work. HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 Pay from vocational program or stipend work(This includes pay from a sheltered job, which is working in a job along with other persons with disabilities) HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 Income from illegal activities such a s sex for money, dealing drugs, or other HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 Other income such as panhandling, picking up returnable cans or bottles("canning") or selling crafts HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 Child support payments. Specify:  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1 Other income not covered above. HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Text.1  In the past 30 days, how many days have you experienced employment problems? [Problems include trouble finding work,  worry about being fired or laid off or not liking the work you do] days In the past 30 days, how troubled or bothered have you been by these employment problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely How important to you NOW is counseling for these employment problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely MEDICAL STATUS How would you rate your overall physical health right now? Excellent Very Good Good Fair Poor How many times in your life have you been pregnant?  Times How many of these pregnancies resulted in a live birth?  Pregnancies Are you pregnant now? 1. Yes 2. No 3. Dont know How many of your children are still living today?  children Have you given birth to a child in the past 12 months? 1. No 2. Yes How many times have you been hospitalized overnight for medical problems: [Do not include hospital stays for alcohol or drug problems, emotional problems or normal child birth]  Number of times hospitalized in your lifetime? times  Number of times hospitalized in the past 6 months? times  In the past 30 days, how many NIGHTS have you spend in the hospital because of medical problems? [Note: Indicates that the client was admitted and stayed over night] [If none enter 0] In the past 30 days, how many TIMES were you treated for medical problems: in an emergency room? [If None enter 0] as an outpatient? (In a doctor or clinic office) [If None enter 0] Do you have any chronic medical problems, which continue to interfere with your life ? [Chronic Medical Condition: A serious physical condition that requires regular care like diabetes, epilepsy, chronic back pain, high blood pressure, etc.] No Yes Have you ever had any of the following health problems? HepatitisChlamydiaSyphilisGonorrheaHerpesPelvic InflammatoryHIV+AIDS Have you ever had a fit or seizure? 1. No 2. Yes Are you taking any prescribed medication on a regular basis for a physical problem [Note: Include medicines prescribed whether or not you are currently taking them] Yes No Do you receive a pension for a physical disability? [From any source such as the VA, social security, or workmans compensation] No Yes In the past 30 days, how many days have you experienced medical problems? (Including flu, colds or more serious problems)  days In the past 30 days, how troubled or bothered have you been by these medical problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely How important to you NOW is treatment for these medical problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely DRUG & ALCOHOL USE Have you ever used any of the following drugs? NOTE: If NEVER used, type 0 under in your Lifetime. If used less than 1 year but at least once, type 1 under In Your Lifetime. In Your Lifetime Past 30 Days (Years) (days)  Alcohol (Beer, Liquor, Wine, etc)  Heroin  Marijuana/Hashish (Pot, Hash, etc.) Cocaine - Powder  Crack  Amphetamines/Methamphetamines (Speed, Uppers, Ritalin, Benzedrine, Dexedrine, Preludine, and Other Amines, and Related Drugs)  Barbiturates (Phenobarbial, Seconal, Nembutal, Barbs, Reds, etc.)  Benodiazepines (Xanax, Valium, Ativan, Tranquilizers, Sleeping Pills, Diazepam, Flurazepam, Chlordiazepoxide, Clorazepate, Lorazepam, Alpraolam, Oxazepam, Emazepam, Triazolam, Clonazepam, Halazepam)  Ecstacy (XTC, MDMA)  GHB  Hallucinogens LSD (Acid)  Hallucinogens PCP (Angel Dust)  Hallucinogens Other (Peote, Mushrooms, Mescaline, Psilocybin etc.)  Inhalants (Poppers, Amyl Nitrate, Nitrous Oxide (whipits), Paint Thinner, Chloral Hydrate, Glue, Ether, lacidyl, Doriden, Chloroform, Gasoline etc.)  Ketamine, Special K Methadone (Non-Prescription)  Opiate Other (Copdeine, Dilaudid, Morphine, Demorol, Opium and other Drug with Morphine like effects) Oxycontin Rohypnol (Roche, Rope, Roach)  Other, Specify: _______________________  More than 1 substance per day (Includes alcohol) Drug  How old were you when you first used an illegal drug? Years-old  In the past 30 days, how many days have you used drugs? days In the past 30 days, have you injected illegal drugs? Yes No In your life, how many times have you been treated for drug problems? [This includes detox, halfway houses, inpatient/outpatient, counseling, and Narcotics Anonymous (NA) How many of these times were for drug detox only (with no other treatment)? In the past 30 days, how much money would you say you spent on drugs (only count actual MONEY you spent) $_____________ In the past 30 days, how many days have you experienced drug problems? (like craving, withdrawal symptoms, disturbing side effects, or wanting to stop and not being able to) In the past 30 days, how troubled or bothered have you been by these drug problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely How important to you NOW is treatment for these drug problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely Alcohol How old were you when you first used alcohol?  Years-old How old were you when you first got drunk from drinking alcohol?  Years-old In the past 30 days, how many days have you used alcohol?  days In the past 30 days, how many days have you used alcohol to intoxication? days DRUG & ALCOHOL USE (Contd) How many times in your life have you had alcohol DTs? [NOTE: DTs (Delirium Tremens) happen a day or two after your last drink or after you drink a lot less than usual. They include shaking, fever, hallucinations, and confusion/disorientation.]  times In your life how many times have you been treated for alcohol problems? [This includes detox, halfway house, inpatient/outpatient, counseling, and Alcoholics Anonymous (AA)]  times  How many of these treatments were alcohol detox only? Treatments In the past 30 days, how much money would you say you $________ spent on alcohol (only count actual MONEY spent)? In the past 30 days, how many days have you experienced alcohol problems? (Like craving, withdrawal symptoms, disturbing effects of use, or wanting to stop and not being able to)  days In the past 30 days, how troubled or bothered have you been by these alcohol problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely How important to you NOW is treatment for these alcohol problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely In the past 30 days, how many nights have you spent in the hospital because of alcohol and drug problems?  nights In the past 30 days, how many times were you treated for alcohol or drug problems:  in an emergency room? times  as an outpatient? (In a doctor or clinic office) times In the past 30 days, to what extent has your use of alcohol or other drugs caused you to reduce or give up important activities? 1. Not at all 2. Somewhat 3. Considerably 4. Extremely In the past 30 days, to what extent has your use of alcohol or other drugs caused you to have emotional problems? 1. Not at all 2. Somewhat 3. Considerably 4. Extremely LEGAL STATUS How many times in your life have you been arrested and charged with following Lifetime Past Last 6months 30 days Shoplifting. Parole/probation violation. Drug charges.. Forgery. Weapons offense. Burglary/larceny/Breaking & Entering.. Robbery. Assault .. Domestic Violence/ Child Abuse  Prostitution ..  Contempt of court Driving Under the Influence (alcohol or drugs) ..  Disorderly Conduct. Other . If Other, Specify: ____________________ What is your Current Legal Status? No Legal Problem Case Pending Drug Court Probation Parole DWI License Suspension Jail/Prison Inmate DYFS or Family Court Other If other; Specify __________________  How many times have you been arrested and charged for an offense in the past 30 days? How many of these charges resulted in convictions? [Convictions include fines, probation, jail or prison, suspended sentences and guilty pleas] In your life, how much time have you spent in jail or prison all together? 1. None 2. Less than 1 year 3. 1 to less than 3 years 4. 3 to less than 6 years 5. 6 years or more In the past 6 months, how many months have you spent in jail or prison all together?  [If you spent no time in jail or prison, enter 0, If you spent some time in jail or prison but it was less than a month, enter 1] months In the past 30 days, how many nights have you been spend in jail or prison? nights Presently, are you awaiting charges, trial or sentence? No Yes In the past 30 days, how many days have you engaged in illegal activities for profit? [If none enter 0] days How serious do you feel your present legal problems are? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely How important to you NOW is counseling or referral for these legal problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely FAMILY/SOCIAL RELATIONSHIPS What is your current marital status? Never Married Married Widowed Separated Divorced If not married: Are you currently living with a significant other? No Yes Are you satisfied with your current marital status? No Dont Know/Indifferent Yes Check all the people you usually lived with in the past three years (Check al that apply) Spouse/Sex Partner Children Parents Other Family Friends Alone Jail, hospital, halfway house, live-in treatment program Have you been satisfied with your usual living arrangements during the past 3 years? [Note: Satisfied means you generally like your living situation] No Dont Know/ Indifferent Yes How many children do you have, aged 17 or less, whether they live with you or not? [Includes all children by birth, adoption, step-children, etc.) Are any of your children living with someone else because of a Child protection court order? No Yes Do you have an active case with DYFS? No Yes - Continue on Insert 2 Do you live with anyone who has a current alcohol problem? No Yes Do you live with anyone who uses illegal drugs or non-prescribed drugs illegally? No Yes Did anyone physically abuse you or cause you physical harm: In your life? No Yes in the past 30 days? No Yes Did anyone ever force sexual advances or sexual acts on you: in your life? No Yes in the past 30 days? No Yes Have you had any serious problems getting along with your (Yes/No) Lifetime Past 30 days Mother yes no yes no Father yes no yes no Brothers/Sisters yes no yes no Sexual Partner/Spouse yes no yes no Children yes no yes no Other significant family yes no yes no Close Friends yes no yes no Neighbors yes no yes no Co-Workers yes no yes no In the past 30 days, how many days have you had serious conflicts with your family? [If none enter 0]  days How troubled or bothered have you been in the past 30 days by family problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely How important to you NOW is treatment or counseling for family problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely PSYCHIATRIC STATUS In your lifetime, how many times have you been treated for any psychological or emotional problems (do not include treatment for alcohol or other drug problems):  Treated in a hospital or inpatient setting? times  Treated in an Out patient/Private patient setting (where you did not spend the night) times In the past 30 days, how many nights have you spent in the hospital because of psychological or emotional problems? [If none enter 0]  nights In the past 30 days, how many times were you treated for psychological or emotional problems 1. in an emergency room? [If none enter 0] days 2. as an outpatient? (In a doctor or clinic office) [If none enter 0] Do you receive a pension for a psychiatric disability? No Yes Have you experienced serious depression for two weeks or more at a time (feeling badly depressed, sad, hopeless, uninterested in things) that was not from alcohol or drug use: in your life? No Yes in the past 30 days? No Yes Have you experienced serious serious tension or anxiety for two Weeks or more at a time (feeling uptight, unreasonably worried, inability to feel relaxed) while you were not under effects of alcohol or another drug: in your life? No Yes in the past 30 days? No Yes Have you experienced hallucinations (saw things or heard voices that were not there) when you were not under influence of alcohol or another drug: in your life? No Yes in the past 30 days? No Yes Have you had a period in which you have experienced trouble understanding, concentrating, or remembering for two weeks or more at a time while you were not under influence of alcohol or another drug: in your life? No Yes in the past 30 days? 1. No 2. Yes Have you had a period of time in which you have experienced trouble controlling violent behavior (or losing control), rage, or violence: in your life? No Yes in the past 30 days? No Yes Have you had a period of time in which you have experienced serious thoughts of suicide (seriously considered a plan for taking your life): in your life? No Yes in the past 30 days? No Yes Have you attempted suicide: in your life? No Yes in the past 30 days? No Yes Have you been prescribed medication for any psychological or emotional problems for at least 2 weeks or more (even if you did not actually take it): in your life? No Yes in the past 30 days? No Yes In the past 30 days, how many DAYS have you experienced these psychological or emotional problems? [If none, enter 0] days In the past 30 days, how much have you been troubled or bothered by these psychological or emotional problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely How important to you NOW is treatment for these psychological or emotional problems? 1. Not at all 2. Slightly 3. Moderately 4. Considerably 5. Extremely HEALTH RISK  In the past 6 months, how many TIMES have you shared needles with other people? times  In the past 6 months, with how many different PEOPLE have you shared needles? people Which statement best describes the way you cleaned your needles during the past 6 months? I have NEVER used needles I have NOT used needles in the past 6 months I used a new needle EACH TIME I injected drugs in the past 6 months I always cleaned my needle with BLEACH just BEFORE I injected drugs in the past 6 months I SOMETIMES cleaned my needles with BLEACH just BEFORE I injected drugs in the past 6 months I NEVER cleaned my needles with BLEACH when I injected drugs in the past 6 months In the past 6 months, with how many different PEOPLE have you had sex? (sex includes vaginal intercourse, anal intercourse and oral sex)  people How many of these people were the same sex as you? people In the past 6 months, how much of the time did you use condoms when you had sex (sex=vaginal intercourse, anal intercourse or oral sex) No Sex in the past 6 months 2. None of the time 3. Less than half the time 4. About half the time 5. Most of the time 6. All of the time Have you ever been tested for HIV? No Yes If yes, did you get your results? No/Never Yes with all tests Yes with some of the tests Have you ever been tested for Hepatitis? No Yes If yes, did you get your results? No/Never Yes with all tests Yes with some of the tests End of Assessment (ASI)... BioPsychoSocial Counselor Name: Date: Primary Drug Name Alcohol Heroin Marijuana/Hashish Cocaine Powder Crack Amphetamines/Methamphetamines Barbiturates Benzodiazepine Ecstacy GHB Hallucinogens LSD Hallucinogens PCP Hallucinogens Other Inhalants Ketamine, Special K Methadone (non-prescription) Opiate Other Oxycontin Rohypnol (Roche, Rope, Roach) Other Route of administration Intramuscular Inhalation/Sniffng Smoking Intramuscular Frequency of Use No use in past month Less than weekly 1 to 2 times per week 3 to 6 times per week Daily Amount Use Age at First Use Date of Last Use ___________________________ Secondary Drug Name 1. Alcohol 2. Heroin 3. Marijuana/Hashish 4. Cocaine Powder 5. Crack 6. Amphetamines/Methamphetamines 7. Barbiturates 8. Benzodiazepine 9. Ecstacy 10. GHB 11. Hallucinogens LSD 12. Hallucinogens PCP 13. Hallucinogens Other 14. Inhalants 15. Ketamine, Special K 16. Methadone (non-prescription) 17. Opiate Other 18. Oxycontin 19. Rohypnol (Roche, Rope, Roach) 20. Other Route of Administration 1. Intramuscular 2. Inhalation/Sniffing 3. Smoking Intramuscular Frequency of Use 1. No use in past month 2. Less than weekly 3. 1 to 2 times per week 4. 3 to 6 times per week 5. Daily Amount Use Age of First Use Date of Last Use _______ Tertiary Drug Name Alcohol Heroin Marijuana/Hashish Cocaine Powder Crack Amphetamines/Methamphetamines Barbiturates Benzodiazepine Ecstacy GHB Hallucinogens LSD Hallucinogens PCP Hallucinogens Other Inhalants Ketamine, Special K Methadone (non-prescription) Opiate Other Oxycontin Rohypnol (Roche, Rope, Roach) Other Route of administration Intramuscular Inhalation/Sniffing Smoking Intramuscular Frequency of Use No use in past month Less than weekly 1 to 2 times per week 3 to 6 times per week Daily Amount Use Age at First Use Date of Last Use Fourth Drug Name Alcohol Heroin Marijuana/Hashish Cocaine Powder Crack Amphetamines/Methamphetamines Barbiturates Benzodiazepine Ecstacy GHB Hallucinogens LSD Hallucinogens PCP Hallucinogens Other Inhalants Ketamine, Special K Methadone (non-prescription) Opiate Other Oxycontin Rohypnol (Roche, Rope, Roach) 20. Other Route of Administration Intramuscular Inhalation/Sniffing Smoking Intramuscular Frequency of Use No use in past month Less than weekly 1 to 2 times per week 3 to 6 times per week Daily Amount Use Age at First Use Date of Last Use _______ Fifth Drug Name Alcohol Heroin Marijuana/Hashish Cocaine Powder Crack Amphetamines/Methamphetamines Barbiturates Benzodiazepine Ecstacy GHB Hallucinogens LSD Hallucinogens PCP Hallucinogens Other Inhalants Ketamine, Special K Methadone (non-prescription) Opiate Other Oxycontin Rohypnol (Roche, Rope, Roach) Other Route of Administration Intramuscular Inhalation/Sniffing Smoking Intramuscular Frequency of Use No use in past month Less than weekly 1 to 2 times per week 3 to 6 times per week Daily Amount Use Age at First Use Date of Last Use _______ Sixth Drug Name Alcohol Heroin Marijuana/Hashish Cocaine Powder Crack Amphetamines/Methamphetamines Barbiturates Benzodiazepine Ecstacy GHB Hallucinogens LSD Hallucinogens PCP Hallucinogens Other Inhalants Ketamine, Special K Methadone (non-prescription) Opiate Other Oxycontin Rohypnol (Roche, Rope, Roach) Other Route of Administration Intramuscular Inhalation/Sniffing Smoking Intramuscular Frequency of Use No use in past month Less than weekly 1 to 2 times per week 3 to 6 times per week Daily Amount Use Age at First Use Date of Last Use Seventh Drug Name Alcohol Heroin Marijuana/Hashish Cocaine Powder Crack Amphetamines/Methamphetamines Barbiturates Benzodiazepine Ecstacy GHB Hallucinogens LSD Hallucinogens PCP Hallucinogens Other Inhalants Ketamine, Special K Methadone (non-prescription) Opiate Other Oxycontin Rohypnol (Roche, Rope, Roach) Other Route of Administration Intramuscular Inhalation/Sniffing Smoking Intramuscular Frequency of Use No use in past month Less than weekly 1 to 2 times per week 3 to 6 times per week Daily Amount Use _____________________ Age at First Use _______ Date of Last Use _______ Comments: Symptoms/Consequences Tolerance_____ Withdrawal_____ Unsuccessful attempts to cut down_____ Desire/attempts to stop_____ Overdose_____ Delirium tremors_____ Stolen to support use_____ Sold drugs_____ Blackouts_____ Physical/Psychological problems_____ Financial problems_____ Family Problems_____ Using alone/hiding use_____ Injuries_____ Continued use despite negative consequences_____ Excessive use_____ Time spent using_____ Sacrificing activities to use_____ Reduced social activities_____ Role obligations_____ Hazardous use_____ Legal problems_____ Social problems_____ Suicidal/Homocidal Risk Assessment Family history of suicide attempts_____ History of suicide attempt(s)_____ Current suicidal ideation_____ Current suicide plan_____ Current suicidal intent_____ History of depression_____ Current diagnosis for depression_____ Recent and/or multiple losses_____ Current homicidal ideation_____ Current homicide plan_____ Current homicidal intent_____ History of physical assault(s) to others_____ History of being physically or emotionally assaulted_____ Comments: Mental Status (Optional) Appearance: Appears as age___ Older___ Younger___ Dress: Neat___ Soiled___ Meticulous___ Inappropriate___ Causal___ Bizarre___ Disheveled___ Verbal Content: Rate of Speech: Normal___ Slow___ Rapid___ Pressured___ Statements indicate: Appropriateness___ Anger___ Fear___ Negativism___ Anxiety___ Sadness___ Elation___ Delusions___ Tone: Average___ Loud___ Soft___ Orientation: To person___ place___ time___ Memory: Intact___ Impaired Recent___ Impaired Remote___ Judgment: Good___ Fair___ Impaired___ Insight: Good___ Fair___ Impaired___ Thought Processes: Logical___ Illogical___ Disorganized___ Tangential___ Flight of Ideas___ Other___ Emotional State: Normal Affect___ Flat___ Constricted___ Vascilating___ Inappropriate to Content___ Mood: Calm___ Anxious___ Fearful___ Guilty___ Worthless___ Euphoric___ Angry___ Sad___ Hallucinations: Denied___ Auditory___ Visual___ Olfactory___ Tactile___ Taste___ Command___ Delusions: Denied___ Grandiose___ Persecutory___ Somatic___ Obsessions: Yes___ No___ Phobias: Yes___ No___ Eating Habits: Normal appetite___ poor___ excessive___ vomiting___ Purging___ using laxatives___ weight loss/gain___ Sleeping Habits: Normal___ Restless___ Nightmares___ Up Early___ Unable to Sleep (Day/Night)___ Difficulty falling asleep___ Comments: Dangerousness (Optional) Signs of self-mutilation___ Signs of Anorexia/Bulemia___ No verbal/physical aggression___ With verbal threats___ Physical aggression with hands___ Physical aggression with weapons___ Intentionally destroyed property___ Signs of elder abuse___ Other (Specify):_____________________ Own/possesses guns/knives___ Eloped AMA from a psychiatric facility___ Owns/possesses other weapons___ Requested a restraining order___ Restraining order obtained against him/her___ Evicted from residential setting___ History of stalking___ Intentional fire setting___ Run away/eloping from any setting___ Comments: Assessment of Compulsive Behaviors Please identify problematic behavior surrounding:- 1. Food (Sugar, Caffeine etc...) 2. Gambling/Excessive Spending 3. Repeated involvement in abusive relationships 4. Do you participate in self-help groups for any of the above Yes No (if yes) Enter number (1 or 1, 2 or 1, 2,3): Nutritional Profile 1. Height _______ft ________in. 2. Weight: ______ lbs 3. Have you recently lost or gain weight? 1. No 2. No (if yes) how much? _____ lbs Pain Profile 1. Has client experienced pain in the past month? 1. No 2. Yes If yes, on a scale of 1 to 10 (1 being the least and 10 being extreme) 2. How Bad is it (enter number) ? 3. Where in his/her body does client experience the pain? 4. How does the client treat the pain _____________________ (ie. medication, use alcohol/drugs, etc.) DSM-IV AXIS I: DSM Code: Alcohol Abuse 305.00 Alcohol Dependence 303.90 Amphetamine Abuse 305.70 Amphetamine Dependence 304.40 Cannabis Abuse 305.20 Cannabis Dependence 304.30 Cocaine Abuse 305.60 Cocaine Dependence 304.20 Hallucinogen Abuse 305.30 Hallucinogen Dependence 304.50 Opioid Abuse 305.50 Opioid Dependence 304.00 PCP Abuse 305.90 PCP Dependence 304.90 Inhalant Abuse 305.90 Inhalant Dependence 304.60 Poly-Substance Dependence 304.80 No Diagnosis or condition on Axis I V71.09 Diagnosis or Condition Deferred On Axis I 799.9 AXIS II: __________________________________________________________ __________________________________________________________ AXIS III: __________________________________________________________ AXIS IV: __________________________________________________________ __________________________________________________________ AXIS V: __________________________________________________________ __________________________________________________________ COMMENTS FOR DIAGNOSTIC IMPRESSION:  INTERVIEWER SEVERITY RATING How would you rate the patientsNo Tx. NecessarySlightlyModeratelyConsiderablyExtremelyNeed for employment counseling? CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s Need for medical Treatment?  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s Need for alcohol abuse treatment? CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s Need for drug abuse Treatment? CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s Need for legal services or counseling? CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s Need for family and/or social counseling? CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s Need for psychological and/or emotional counseling? CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  CONTROL Forms.TextBox.1 \s   CONTROL Forms.TextBox.1 \s  Evaluation Outcome Date of Evaluation: ____________ Evaluated by: _______________ Referred to Treatment Agency Recommended Level of Care: Standard/Traditional Outpatient OPIOID Maintenance-Outpatient Intensive Outpatient OPIOID Maintenance - Intensive Outpatient Partial Hospitalization Transitional Care /Extended Care Halfway House Long-Term Residential Short-Term Residential (Medically Monitored) Hospital-Based (acute) Residential Detox-Methadone Outpatient Detox-Free-Standing Residential (Sub-Acute) Detox-Hospital Inpatient Detox-Outpatient (Non-Methadone) Non-traditional program Recommended Treatment Agency: _____________________ Date of Referral:____________ Date of Scheduled Appointment: ____________ Is this client enrolled to treatment? Yes No If Client is referred for treatment but not admitted within 45 days of date of referral. Explain: Cultural Appropriateness Education(Developmental Issues Geographic location of services Legal Issues(court Case Pending) Awaiting pre-approval for insurance Provider refuses to pay for service No insurance coverage Noncompliance with treatment recommendations Inpatient with on-site child care unavailable No local service available Other lack of available service Outpatient transportation Outpatient childcare Unable to locate client Inpatient waiting list Outpatient waiting list Rule-out/Deferral In remission Administrative delay Other Did not meet program criteria-Methadone dose too high Did not meet program criteria-Pregnan Did not meet program criteria-Children are wrong ages Did not meet program criteria-Mental Health Diagnosis Languag Taken off by system due to 45 days passed Pending Due to: Waiting available slots/beds Medical Reports/Hospital Approval Psychological Reports Probation/Parole Approval Language Barrier Other, (If other) Specify: Needs Extended Assessment Ext. 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