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20-3D

Treatment Program Biopsychosocial Assessment

Inmate Name: Number:


Age: Gender: DOB: Race:
Last City of Residence: Emergency Contact:
Length of Sentence: Referral Source:
Program Type: Program Location:
Admission Date: Date of Assessment:

Presenting Problem:

Alcohol/Drug History:
Name of Drug Age of Drug of Choice Frequency of Use (Daily, Length of Use Route of
Onset (list first three) Weekly, Monthly) (years) Administration

Alcohol
Cocaine
Crack Cocaine
Marijuana
Heroin
Other Opiates
Barbiturates
Amphetamines
Hallucinogens
Inhalants
PCP
Route of Administration: 1. Oral, 2. Nasal, 3. Smoking, 4. Injection

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20-3D

1. How did you support your using habit? Check all that apply:

family friends growing stealing


working selling manufacturing prostitution
2. When did your using take place? _______________________________________________________________
3. With whom? _______________________________________________________________________________
4. Have you tried to cut down on your use? _________________________________________________________
5. Have you ever tried to stop using? ______________________________________________________________
6. Have you ever substituted your drug of choice with another drug to control your use? ____________________
7. Have you ever drank or used in the morning to relieve the shakes or to take the edge off? _________________
8. Have you used one drug to change the effects of another drug? ______________________________________
9. How many times have you experienced blackouts? _________________________________________________
10. How many times have you overdosed? ___________________________________________________________
11. Why did you use? Check all that apply:

make friends easily deal with anger feel in control


work/study better be less critical of self feel adequate
feel accepted by others relieve depression avoid things
feel comfortable with sex feel more confident relax or unwind
feel more alert forget anger feel happy
feel more tolerant of others help me sleep other

12. Did you use to alter your feelings in any of the following ways? Check all that apply:

happy guilty sad nervous


bored “hyper” depressed tired
lonely worried angry frustrated

Counselor Comments:

Prior Treatment History


Complete the following chart listing all past treatment experiences. Use the treatment codes below to indicate
treatment modality.
Year Treatment Reason for Treatment Length of Discharge Reason Response to Treatment
Code Stay

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Treatment Code
1. Jail
2. Outpatient Substance Abuse/Mental Health
3. Inpatient /Residential Substance Abuse/Mental Health
4. Detoxification Unit
5. Drug Court
6. Prison Outpatient Substance Abuse
7. Prison Residential Substance Abuse
8. Other ______________________

Counselor Comments:

Medical History:
1. Have you ever had or do you currently have any of the following conditions:

Allergies Knife Wounds Hepatitis B Pelvic Inflammatory


Gunshot Wounds Hepatitis C Disease
Cirrhosis Tuberculosis Venereal Disease Seizures
HIV/AIDS Head Injury Back Injury Other (List)

2. What treatment have you received or are currently receiving for this/these conditions? ____________________
___________________________________________________________________________________________.
3. Are you currently taking any prescription medications? ________ If yes, what medications? _________________
____________________ _______________________________________________________________________
4. How long have you been taking it? _________________ What is your current dosage? _____________________
Name of prescribing doctor? ____________________________________________________________________
5. Have you ever had surgery? ____________ If yes, for what condition(s)? ________________________________
___________________________________________________________________________________________
6. Have you ever been hospitalized? _______ If yes, for how long? _______________________________________
For what condition(s)? _________________________________________________________________________
7. Do you have any current medical problems for which you need treatment? _____________ What condition(s) __
___________________________________________________________________________________________

Counselor Comments:

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20-3D

Mental Health History:


Have you ever: Within last 30 days In your lifetime?
1. Experienced serious depression, sadness, hopelessness, loss of
interest, or difficulty with daily function?
2. Heard voices or saw things that others did not see or hear?
3. Experienced episodes of rage or violence?
4. Attempted or had serious thoughts of homicide?
5. Serious anxiety or tension?
6. Attempted or had serious thoughts of suicide?
7. Practiced self-mutilation?
8. Received outpatient treatment for mental health problems?
9. Received inpatient treatment for mental health problems?
10. Taken medication for mental health problems?

If yes to any of the above, please explain: ________________________________________________________________


__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Do you have current homicidal or suicidal thoughts? ____________ Please describe: _____________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Counselor Comments:

Family History:
1. What is your current marital status? _____________________________________________________________
2. How many times have you been legally married? ___________ If currently married, how long? _____________
If not currently married do you have a significant other? _____________________________________________
3. How many children do you have? ______________ Under 18? ____________ Over 18? ____________________
4. Where and with whom are your children currently living? ____________________________________________
5. How often do you communicate with your spouse/significant other? ___________________________________
6. How often do you communicate with your children? _________________________________________________
7. Are you satisfied with the amount of communication you have with your significant other? _________________
8. Are you satisfied with the amount of communication you have with your children? ________________________
9. Please provide comments about your relationships with your significant other and children. _________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
10. With whom did you live while growing up? ________________________________________________________

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11. How many siblings do you have? _____________ Brothers? ____________________ Sisters? _______________
12. Please describe your relationships with your parents/caregivers and siblings while growing up. ______________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
13. How often do you communicate with your parents/caregivers? _______________________________________
14. How often do you communicate with your siblings? _________________________________________________
15. Are you satisfied with the amount of communication you have with your parents/caregivers? _______________
16. Are you satisfied with the amount of communication you have with your siblings? _________________________
17. Please describe your relationships with your parents/caregivers and siblings as an adult. ___________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
18. Which of your family members do you feel closest to? _____________________ Why? ____________________
_______________________________________________________________________________________________
19. Do any of your family members use drugs/alcohol? __________ Which members? ________________________
_______________________________________________________________________________________________
20. Are any of your family members deceased? _________________ Which members? ________________________
_______________________________________________________________________________________________

Counselor Comments:

Abuse History:
1. How would you describe the discipline you received while growing up?
Very Strict Moderate Inconsistent
Permissive Abusive No Discipline At All

2. How were you punished as a child? ______________________________________________________________


_______________________________________________________________________________________________
3. Were you ever abused as a child? _________ If yes, _______Physically? _______Emotionally? _______Sexually?
4. By who were you abused? ____________________________________________________________________
5. Have you been abused since you have been an adult? ____ If yes, please explain. _________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
6. Have you ever been accused of abusing your children? ______________Spouse or Significant Other? _________
Parents? __________ If yes, please explain. ________________________________________________________
______________________________________________________________________________________________

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Counselor Comments:

Educational/Vocational History and Economic Status:


1. How many years of high school have you completed? _________ ___ Diploma? _________GED? ____________
2. How many years of college have you completed? ________________ Degree? __________________________
3. Describe any difficulties you have in:
Reading: ____________________________________________________________________________________
Writing: ____________________________________________________________________________________
Comprehension: ______________________________________________________________________________
4. What future education plans do you have? ________________________________________________________
_______________________________________________________________________________________________
5. What vocational training have you received? ______________________________________________________
6. List all trades for which you are certified/licensed : __________________________________________________
_______________________________________________________________________________________________
7. Complete the following chart for your last three jobs:
Employer Type of Work Salary/Wage Length of Reason for Leaving
Service

8. Have you ever lost any jobs due to alcohol and/or drug use? ________________ How many? ________________
9. Have you ever used while working or worked while under the influence? ________________________________
10. What future vocational plans do you have? ________________________________________________________
_______________________________________________________________________________________________
11. What economic resources do you have available to you upon release from incarceration? __________________
_______________________________________________________________________________________________
12. Describe any financial problems or fears: __________________________________________________________
_______________________________________________________________________________________________
13. What will be your living arrangements upon release from incarcerations? ________________________________
_______________________________________________________________________________________________

Counselor Comments:

Social/Cultural History:
1. Do you have any close friends? __________ If yes, how long have you known them? _______________________
2. Describe your relationship with your close friends: __________________________________________________
_______________________________________________________________________________________________
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20-3D

3. If you do not have any close friends, with whom do you associate? _____________________________________
4. Describe your relationship with your associates? ____________________________________________________
_______________________________________________________________________________________________
5. With whom do you use? _______________________________________________________________________
6. Do you have any close friends or associates who do not use? ________ If yes, describe your relationship with
these persons: _______________________________________________________________________________
_______________________________________________________________________________________________
7. Have you had contact with any of your close friends/associates since you have been incarcerated? ___________
8. Are you satisfied with the amount of communication you have with these persons? _______________________
9. Have you ever been associated with a 12-step or other self-help group? _________________________________
10. If yes, do you have a sponsor or close friend associated with that group? ________________________________
11. What ethnic/cultural influences have been most important to you? ____________________________________
_______________________________________________________________________________________________
12. Do you think these influences have contributed to your drug/alcohol use? _______________________________

Counselor Comments:

Spiritual/Leisure History:
1. With which religious denomination do you associate yourself? ________________________________________
2. How often do you participate in activities associated with this religious denomination? _____________________
3. Do you have spiritual beliefs or practices that are not associated with any religious denominations?___________
4. Describe your spiritual beliefs/practices: __________________________________________________________
_______________________________________________________________________________________________
5. Do you believe in the concept of a "Higher Power"? ____ If yes, do you have a Higher Power? ______________
6. How do you use your "Higher Power"? ___________________________________________________________
_______________________________________________________________________________________________
7. If you do not believe in the concept of a "Higher Power" do you have another system of belief? _____________
8. Describe that system of belief: __________________________________________________________________
_______________________________________________________________________________________________
9. Do you have a mentor or close friend associated with your spiritual beliefs? ______________________________
10. How do you spend your leisure time? _____________________________________________________________
11. What are your hobbies? _______________________________________________________________________
12. Do you participate in any sport activities? _________________________________________________________
13. How does you drug/alcohol use affect your participation is leisure activities? _____________________________
_______________________________________________________________________________________________
14. Do you have any close friends/associates who do not use with whom you interact during your leisure time? ___

Counselor Comments:

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20-3D

Sexual History/HIV Assessment:


1. Is your sexual preference; Men_________________ Women________________ Both ____________________?
2. Have you had more than one sexual partner in the past 10 years? __________ If yes, check on of the following:
2-5 partners ______________ 5-10 partners________________ 10 or more partners_____________
3. Have you ever been forced to have sex against your will? _____________________________________________
4. Have you ever had sexual relations while under the influence of drugs and/or alcohol? _____________________
5. Have you ever received money, drugs, alcohol, or other currency for sex? _______________________________
6. Do you have, suspect you have or have you ever had any of the following sexually transmitted diseases:
Herpes Gonorrhea Syphilis
HIV/AIDS Chlamydia Genital Warts
7. To your knowledge, have you ever had sexual contact or shared
needles with anyone who had AIDS or HIV infection (the AIDS virus)
or who later developed AIDS or HIV infection? Yes _____ No ______

8. Have you ever had, or are you now having, sexual relations with a
person of the same sex as yourself? Yes _____ No _____

9. Have you ever had sexual relations, to your knowledge, with a man
who has had sex with another man? Yes _____ No _____
10. Have you engaged in:
Sex with a known/suspected bisexual? Yes _____ No _____
Sex with a known/suspected IV drug user? Yes _____ No _____
Sex with a prostitute? Yes _____ No _____
Prostitution? Yes _____ No _____
IV Drug Use Yes _____ No _____
Sex with 2 or more partners in a 12 month period? Yes _____ No _____
11. Have you ever been exposed to and/or tested (to your knowledge) for:
Tuberculosis (TB) Yes _____ No _____
Hepatitis B? Yes ____ No _____
12. Have you received a blood transfusion since 1977? Yes_____ No _____

Counselor Comments:

Legal History:
1. What is your current incarcerating offense? _______________________________________________________
2. Is this incarceration due to a parole or probation violation? ___________________________________________
3. How long is your sentence? _________________How much time do you have left to serve? _________________
4. Have you ever been court-ordered substance abuse treatment and/ or evaluation? ________________________
5. How many times have you ever been to jail or prison, including juvenile facilities? _________________________
Before age 18 As an Adult Last year before Incarceration Total years incarcerated

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6. How many times have you been arrested or charged with any of the following?
Type of Crime Age at In Last Year Total
First before Number of
Arrest Incarceration times
Arrested
1. Public intoxication from drinking alcohol
2. DUI as a result of alcohol consumption
3. Use of other illegal drugs
4. Possession of other illegal drugs or drug paraphernalia
5. Sale, distribution, or manufacturing of any drug
6. Forgery or fraud (bad checks, running con games, etc.)
7. Fencing/buying, receiving, selling, pawning stolen
property
8. Gambling, running numbers, or bookmaking
9. Prostitution or Pandering (pimping)
10. Burglary or auto theft
11. Other theft (larceny, shoplifting, etc.)
12. Violence against another person (homicide, aggravated
assault, kidnapping, etc.)
13. Sex offenses (rape, aggravated sexual assault, lewd and
lascivious, indecent exposure)
14. Arson offenses
15. Parole/Probation Violation
16. Weapons offenses
17. Vandalism, vagrancy, loitering
18. Others (specify)

7. How many of these arrests were drug related (while using or to get drugs)? ______________________________
8. 8. How many of these arrests were while earning money in drug-related activities? _______________________
9. During this incarceration how many disciplinary reports have you received? ______________________________
10. Have you ever carried a weapon? ____________________ If yes, how often? ____________________________
11. Do you have any pending charges? __________________ If yes, for which crime(s)? ______________________

Counselor Comments

Military History:
1. Have you ever served in the military? __________________________ Which branch? _____________________
2. What was your highest rank? ___________________________________________________________________
3. How long did you serve? _______________________ What was your discharge status? ____________________
4. If other than honorable, please explain: ___________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

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20-3D

Counselor Comments:

Interest in Treatment and Treatment Expectation:


1. Do you think your drug/alcohol usage is a problem for you? _____ Explain: _____________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2. Do you think you can benefit from participation in a substance use disorder treatment program? ____________
Explain: _____________________________________________________________________________________
___________________________________________________________________________________________
3. Has anyone in your social circle ever suggested that you drug/alcohol usage is a problem for you? ____________
4. If yes, who? _________________ Explain: _________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
5. What characteristics do you have that you can use to help you successfully complete a substance use disorder
treatment program? __________________________________________________________________________
___________________________________________________________________________________________
6. What do characteristics do you have that could stop you from successfully completing a substance use disorder
treatment program? __________________________________________________________________________
___________________________________________________________________________________________
7. What expectations do you have about participating in a substance use disorder treatment program? ________
___________________________________________________________________________________________
8. What benefits would you like to receive from participating in a substance use disorder treatment program?
___________________________________________________________________________________________
___________________________________________________________________________________________
9. Is there anything that I haven't asked that you would like to add? ______________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Counselor Comments:

Mental Status Exam and Counselor Assessment:


1. Clients' affect and mood:

appropriate anxious angry


euphoric flattened other
depressed ( ____ severe ____ moderate ____ mild)

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20-3D

2. Client's physical appearance;

neat overweight poor hygiene


disheveled underweight other

3. Client's speech:

normal slow response loud voice


soft voice slurred speech other

4. Client was alert and oriented to :

person place
time situation

5. Client's insight:

good blames others


denies problems other

6. Client's judgment:

intact questionable
impaired poor impulse control

7. Client was:

easy to talk to cooperative motivated for treatment


self-confident assertive honest in responding
paying attention easily distracted clearly expressing thoughts and feelings
thinking clearly guarded in denial about problems

8. Did the client display any of the following:


________ thought disorder
________ memory loss ( ___ short-term ___ long-term ___ both)
________ hallucinations ( ___ visual ___ auditory ___ both)
________ psychosis
________ delusions

Counselor Comments:

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20-3D

DSM-V Diagnostic Criteria for Substance Use Disorders


Please select the answer that most closely represents the participant's experience: Yes No
1. Substance is often taken in larger amounts or over a longer period of time.
2. There is a persistent desire or unsuccessful effort to cut down or control use.
3. A great deal of time is spent in activities necessary to obtain, use, or recover from the effects of
the substance.
4. There are cravings or a strong desire to use the substance.
5. Recurrent substance use results in a failure to fulfill major role obligations at work, school, or
home.
6. There is continued use despite having persistent or recurrent social or interpersonal problems
cause or exacerbated by the effects of the substance.
7. Important social, occupational, or recreational activities are given up or reduced because of
substance use.
8. There is recurrent substance use in situations in which it is physically hazardous.
9. Substance use is continued despite the knowledge of having persistent or recurrent physical or
psychological problems that are likely to have been caused or exacerbated by substance use.
10. There is tolerance, as defined by either of the following:
a. A need for markedly increase amounts of the substance to achieve intoxication or the
desired effect.
b. A markedly diminished effect with continued use of the same amount of the substance.
11. There is withdrawal, as manifested by either of the following:
a. The characteristic withdrawal symptoms for the substance.
b. Substance is taken to relieve or avoid withdrawal symptoms.

Please specify substance use severity for each applicable substance:


Number of Symptoms 2-3 4-5 6 or more
Substance Use Disorder Mild Moderate Severe Diagnostic Impression
Alcohol 305.00 303.90 303.90
Cannabis 305.20 304.30 304.30
Phencyclidine 305.90 304.60 304.60
Other Hallucinogen 305.30 304.50 304.50
Inhalant 305.90 304.60 304.60
Opioid 305.50 304.00 304.00
Amphetamine 305.70 304.40 304.40
Cocaine 305.60 304.20 304.20
Other Stimulant 305.70 304.40 304.20
Sedative, Hypnotic, or Anxiolytic 305.40 304.10 304.10

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20-3D

Narrative Summary: (Include Client Strengths and Weaknesses and Diagnostic Impressions)

RudolphKolderBA BS MA ATC

VanessaHernandezMA LISAC LAC

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20-3D

Treatment Recommendations:
Use index number in identifying problem areas:
1. Substance Abuse 4. Family 7. Vocation/Economic
2. Medical 5. Abuse 8. Legal Problem
3. Mental Health 6. Education 9. Social
Index # Problem List:

Index # Recommendations List:

_______________________________ ____________________
Counselor Signature/Credentials Date

_______________________________ ____________________
Treatment Manager Signature/Credentials Date

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