Family/Significant Other (SO) Admission Self-Assessment

Rosecrance is a behavioral health care organization that is bound by strict state and federal privacy and confidentiality regulations. Please fax this form. Do not email.

Family/Significant Other (SO) Admission Self-Assessment

Client name ____________________________________________ Date of birth ____________________

FAMILY MEMBER

Name ___________________________________________________ Relationship _____________________ Daytime phone: ______________________________ Evening phone: ______________________________ Cellular phone: ______________________________ Best time to call: _____________________________

How long have you know the client? _________________________________________________________ How long do you believe the client has had an addiction problem? ______________________________ To your knowledge, how long has the client been using drugs or alcohol? ________________________

Please describe what made you realize that your loved one may have a problem? __________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Were there any significant incidents that happened in the client's early years, such as divorce, death, abuse, etc? _______________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

How do you feel about your loved one being in treatment?

o Good o Bad o Relieved o Ashamed o It's all my fault o Indifferent o Angry o Other: ____________________________________________________________________________

How have you and your family sufferered as a result of your loved one's chemical use?

o Physical altercations o Verbal altercations o Social embarrassment o Financial distress o Community embarrassment o Legal problems o Excessive worry o Infidelity o Stolen money/credit cards o Broken promises o Employment problems o Educational problems o Insomnia o Depression o Other loved ones have suffered because focus has been on the client o Other: ______________________________________________________________

_______________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

Family/Significant Other Self-Assessment (cont.)

BEHAVIORAL/EMOTIONAL

Has he/she ever shown signs of depression? Yes o No o Explain _____________________________

Has he/she ever expressed suicidal thoughts? Yes o No o Explain _____________________________

Has he/she ever has suicidal plans?

Yes o No o Explain _____________________________

Has he/she ever attempted suicide?

Yes o No o Explain _____________________________

Has he/she ever exhibited violent behavior? Yes o No o Explain _____________________________

How does the patient deal with problems? ___________________________________________________

__________________________________________________________________________________________

ADOLESCENT CLIENTS ONLY Has your son/daughter left home? Has your son/daughter left school? Has your son/daughter left a job?

Yes o No o Explain _____________________________ Yes o No o Explain _____________________________ Yes o No o Explain _____________________________

Has the client experienced any of the following, especially related to withdrawal from drugs?

Tremors

Yes o No o Describe _____________________________________

Sweats

Yes o No o Describe _____________________________________

Nausea/vomiting

Yes o No o Describe _____________________________________

Hallucinations

Yes o No o Describe _____________________________________

Seizures

Yes o No o Describe _____________________________________

History of alcohol or drug overdose Yes o No o Describe _____________________________________

History of IV drug use?

Yes o No o Describe _____________________________________

History of sedative use?

Yes o No o Describe _____________________________________

ADOLESCENT CLIENTS ONLY

Has your son/daughter engaged in an act of self mutilation?

Has your son/daughter exhibited verbal aggression?

Has your son/daughter engaged in an act of physical aggression?

Yes o No o Age of onset __________ Last episode __________ Describe ________________________________________________

Yes o No o Age of onset __________ Last episode __________ Describe ________________________________________________

Yes o No o Age of onset __________ Last episode __________ Describe ________________________________________________

Are there guns in the home?

Yes o No o

Family/Significant Other Self-Assessment (cont.)

Client name ____________________________________________ Date of birth ____________________

LEGAL HISTORY

Date

Offense

Current status

Is the client on parole or probation? No o Yes o Reason: ____________________________________ When was the first time arrested? _____________ Reason: ______________________________________

MEDICAL HISTORY Has the client ever received treatment for drug/alcohol use? No o Yes o How many times: _______

Facility

Dates

Reason

Outcome

Has the client ever been treated for an emotional or psychiatric condition? (If yes, please describe.)

Facility

Dates

Reason

Outcome

FAMILY HISTORY OF CHEMICAL DEPENDENCY

Family member

Current

Father Mother Brother Sister Paternal grandparents Maternal grandparents Children

History

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