Alcohol/Drug Assessment Intake Form

DEMOGRAPHIC INFORMATION

Client’s Name*

Age

Date of Birth

Address

City

State

Zip

Home Phone*

Cell Phone*

Email*

Type of residence (Apt. Home, Duplex, Etc.)

Do you: Rent Own

How long have you lived at this address?

With whom do you live?

What circumstances led to this assessment?

What is your behavior like when you are using alcohol or drugs?

Who referred you or how did you hear about me?

SOCIAL INFORMATION

Number of meaningful relationships

Marital Status: Never married
Married
Unmarried couple
Separated
Divorced
Widowed

How long at present status?

Married how many times?

Spouse’s name

Occupation

Employer

CHILDREN INFORMATION

How many children do you have? (Please list) None 1 2 3 or more

Name

Age

Name

Age

Name

Age

Name

Age

Name

Age

Name

Age

FAMILY INFORMATION

How has your relationship with family/significant other been affected by your chemical use?

How has your chemical use affected the relationship with your children? Yes No

Does anyone in your immediate family have a problem with chemicals?

Have concerned person(s) complained about your use of chemicals? Yes No

Explain

Where were you raised

By whom were you raised?

Father’s name

Father’s occupation

His age

Is your Father living? Yes No

If not, cause of death

Mother’s name

Mother’s occupation

Is your Mother living? Yes No

Her age

If not, cause of death

Parent’s relationship: Married
Divorced
Never Married

Number of children in your family (counting yourself)?

Which number child were you?

Are your brother(s) living? Yes No

Sister(s) living? Yes No

Any history of alcoholism in your family? Yes No

PERSONAL INFORMATION

What are your interests/hobbies?

What do you normally do with your leisure time?

How many close friends do you have?

Do you socialize with people who use drugs and/or alcohol? Yes No

Are you a member of a racial or minority group? Yes No

Religious preference?

Affectional orientation: Heterosexual
Bi-Sexual
Gay
Other

Have you ever been physically or sexually abused? Yes No

What is your attitude toward the use of alcohol and/or drugs?

How do you feel about seeking this assessment?

What do you think of yourself?

What are some personal strengths?

What do you see as problem areas?

How has your chemical use affected your self esteem?

How has your chemical use affected you sexually?

GAMBLING INFORMATION

Have you ever bet on horses, dogs or sporting events? Yes No

Do you enjoy dice games such as craps? Yes No

Have you ever played the following: Lottery
Poker
Slot Machines
Stock Market
Bingo
Pull Tabs

Other

What is the largest amount of money you ever gambled on at one occasion ?

Have you ever gambled more than you intended? Yes No

EDUCATION / VOCATION INFORMATION

What is your highest grade in school?

Name and place of High School

College

Degree

Name and place of College

List any special training

Has your chemical use affected your education plans? Yes No

Explain

Do you have any reading or writing problems? Yes No

Current employer

How long?

Occupation

Do you like your job? Yes No

Do you feel suited for your job? Yes No

Is your job in jeopardy now? Yes No

Do you have an employee assistance counselor? Yes No

Name

Telephone Number

How has chemical use affected your occupational plans? Yes No

How has chemical use affected you financially

Previous consistent employment

Does anyone contribute to your support? Yes No

MILITARY HISTORY INFORMATION

Were you in the Armed Forces? Yes No

Branch

Total time in service

Highest Rank

Were you in combat? Yes No

Wounded of injured? Yes No

Any disciplinary action? Yes No

Explain

Were they chemical- related? Yes No

Type of discharge

CHEMICAL USE HISTORY

Drug of choice

Substance Age & year Pattern?

How much?

Date of last use

ALCOHOL

Date of first use

How often?

MARIJUANA

Date of first use

How often?

LSD

Date of first use

How often?

MUSHROOMS

Date of first use

How often?

AMPHETAMINES

Date of first use

How often?

STEROIDS

Date of first use

How often?

INHALANTS

Date of first use

How often?

DIET PILLS

Date of first use

How often?

COCAINE

Date of first use

How often?

CRACK

Date of first use

How often?

METH

Date of first use

How often?

ECSTACY

Date of first use

How often?

HEROIN

Date of first use

How often?

PCP

Date of first use

How often?

PAINKILLERS

Date of first use

How often?

VALIUM

Date of first use

How often?

SLEEPING PILLS

Date of first use

How often?

I.V.

Date of first use

How often?

OTHER

Date of first use

How often?

Percent of leisure time spent drinking/using?

Longest period of abstinence

How often have you tried to quit?

Result?

Withdrawal symptoms?

AA or self help group attendance?

NICOTINE USE HISTORY

Do you smoke? Yes No

If yes, how much?

Have you stopped smoking? Yes No

Do you have a desire to stop smoking? Yes No

TREATMENT HISTORY

Month/Year Agency name Location # days Reason for service (Include DWI classes, detox, CD treatment, psychological/medical hospitalization in the last 6 months counseling/illness/accidents.)

LEGAL HISTORY

Month/year Location Offense/charge Outcome BAC Chemica

Court action pending Yes No

PROBATION OFFICER/SOCIAL WORKER

Name

County

Address

City

State

Zip

Phone

Fax

MEDICAL / PSYCHOLOGICAL HISTORY

Health status

Date of last physical

Phone

Address

City

State

Zip

Who is your personal physician?

Do you have any history of eating disorders? Yes No

Anorexia/bulimia/compulsive overeating? Yes No

What medical problems, if any, are you currently having?

Are these problems being treated? Yes No

By whom?

What diseases run in your family?

Check any of the following diseases/symptoms you have had: Tuberculosis
Pneumonia
Emphysema
Asthma
Head Injury
Anemia
Rheumatic fever
Hepatitis
HIV positive
History of withdrawal symptoms or blackouts
Thyroid disorder
Arthritis
Diabetes
Communicable Disease
Glaucoma
Cancer
Epilepsy
Stroke
Heart disease
Kidney disorder
High blood pressure
Bleeding tendencies
History of seizures
Jaundice
Headaches
Tachycardia (increased pulse over 100)
Weakness or limb numbness
Liver disease
Ulcer (stomach)
Nervous breakdown or disorder
DT’s, Agitation or Hallucinations
Eating disorders/Obesity or cachectic (wasted) state

What medications are you currently using?

Do you have any allergies to medications? Yes No

Do you have any other allergies? Yes No

List past hospitalizations, operations or serious illnesses: Type of illness/Operation Year Hospital/Doctor

Have you ever had psychiatric treatment? Yes No

When

Have you ever attempted suicide? Yes No

When

Have you ever overdosed from a drug? Yes No

When

Do you have any vulnerable adult issues? Yes No

FOR FEMALES ONLY

Menstrual period: Regular
Irregular
Painful

Date of last menstruation:

Are you or do you think you are pregnant? Yes No

Number of live births?

Number of abortions?

What type of birth control are you using?

Have you been treated for female disorders? Yes No

DRUG/ALCOHOL USE

Please mark each of the following that you have experienced as it relates to drug/alcohol use: using 1 or more times a week to intoxication
using drugs or alcohol to function in a social setting
driving while impaired by drugs or alcohol
loss of friends due to using behavior
tolerance (needing more to get the same effect
mood swings
people complaining about chemical use
fights or conflicts with others while under the influence
daily use
family history of alcohol/drug use
frequently using larger amounts than planned
inability to set or follow through with limits of use
spending a good deal of money on drugs/alcohol
using despite medical/medication issues continuing substance use despite knowledge of persistent or recurrent physical or psychological problem caused by use
hangovers
secretive use
using alone
repeated attempts to control use
persistent desire to cut down use
giving up/reducing activities in order to use
failure to meet obligations at home, school or work
using in the morning
using to medicate thoughts, feelings or physical pain
preoccupation ( thinking about or planning to use)
using rapidly to get a buzz
passing out from using
protecting one’s supply
IV use, injecting
drug/alcohol related legal problems
not remembering using events

MAST SCREENING

Do you feel you are a normal user/drinker? Yes No

Have you ever awakened the morning after some heavy drinking/using the night before and found that you could not remember a part of the evening before? Yes No

Does your spouse (or parents) ever worry or complain about your drinking/using? Yes No

Can you stop drinking/using without a struggle after one of two? Yes No

Do you ever feel bad about your drinking/using? Yes No

Do friends or relatives think you are a normal user/drinker? Yes No

Do you ever try to limit your using/drinking to certain times of day or to certain places? Yes No

Are you always able to stop drinking/using when you want to? Yes No

Have you ever attended a meeting of Alcoholics Anonymous (AA)? Yes No

Have you ever gotten onto fights when drinking/using (physical/verbal)? Yes No

Has drinking/using ever created problems with you and your spouse/family? Yes No

Has your spouse (or family) ever gone to anyone for help about your drinking/using? Yes No

Have you ever lost friends or girlfriends/boyfriends because of drinking/using? Yes No

Have you ever gotten into trouble at work because of drinking/using? Yes No

Have you ever lost a job because of drinking/using? Yes No

Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking/using? Yes No

Do you ever drink/use before noon? Yes No

Have you ever been told you have liver trouble or health problems because of your drinking/using? Yes No

Have you ever had delirium tremors (DT’s), severe shaking, heard voices or seen things that weren’t there after heavy drinking or using? Yes No

Have you ever gone to anyone for help about your drinking/using? Yes No

Have you ever been in a hospital because of your drinking/using? Yes No

Have you ever been a patient in a psychiatric hospital or on a psychiatric ward for a general hospital with a drinking/using related problem? Yes No

Have you ever been a patient in a psychiatric or mental clinic, gone to a doctor, social worker or clergyman for help with an emotional problem in which drinking/using was related? Yes No

Have you ever been arrested, even for a few hours, because of drinking/using behavior? Yes No

Have you ever been arrested for drunk driving or driving after using? Yes No

For most people who drink, alcohol is a pleasant addition to eating and to other social activities.

Have you ever felt you should cut down on your drinking? Yes No

Have people annoyed you by criticizing your drinking? Yes No

Have you ever felt bad or guilty about your drinking? Yes No

Have you ever had a drink first thing in the morning (as an “eye opener”) to steady your nerves or get rid of a hangover? Yes No

Consent

TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS TRUE AND FACTUAL.

Digital Client Signature:

Date

Verification

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