Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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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1. How did you support your using habit? Check all that apply:
12. Did you use to alter your feelings in any of the following ways? Check all that apply:
Counselor Comments:
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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:
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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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
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Counselor Comments:
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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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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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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Counselor Comments:
Counselor Comments:
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3. Client's speech:
person place
time situation
5. Client's insight:
6. Client's judgment:
intact questionable
impaired poor impulse control
7. Client was:
Counselor Comments:
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Narrative Summary: (Include Client Strengths and Weaknesses and Diagnostic Impressions)
RudolphKolderBA BS MA ATC
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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:
_______________________________ ____________________
Counselor Signature/Credentials Date
_______________________________ ____________________
Treatment Manager Signature/Credentials Date
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