Department of Human Services (DHS)
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)
If you have any questions please call customer service at
Phone: 609-292-3331; 609-943-5905; 609-292-1466
Email: kyukyu.hlaing@dhs.state.nj.us or 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
Client’s:
_____________ __________ ____________
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?
1. Central American
2. Dominican
3. Puerto Rican
4. Cuban
5. Mexican
6. South American
7. Other (Specify) ____________________________
What is your race? 1. Black or African American
2. American Indian
3. Native Hawaiian/other Pacific Islander
4. Alaska Native
5. Asian
6. White
7. Other (Specify) ________________________
Living Arrangement at Pre-Admission:
1. Homeless-Shelter
2. Homeless-Streets
3. Dependent Living/Institution
4. Independent Living
Contact Restrictions (Y/N):
Explain: ________________
Primary Language:
1. English
2. Spanish
3. Other
If Other, Specify: ____________________________
Secondary Language:
1. English
2. Spanish
3. Other
If Other, Specify:_____________________________
In what country were you born? [pic] [pic]
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?
1. Self
2. Spouse/Partner
3. Parent
4. Grandparent
5. 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 Cont’d
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 driver’s license?
1. No
2. Yes
Do you have an automobile available?
1. No
2. Yes
What is the highest grade you completed in school?
Do you have a high school diploma or GED
1. No
2. Yes
Are you currently enrolled in school or a job training program?
1. 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
2. Enrolled Full –Time
3. Enrolled Part –Time
4. Other
Which best describes your CURRENT employment situation?
1. Full-time work or military (35 hours a week or more)
2. Part-time (regular hours)
3. Part-time (not regular hours)
4. Student
5. Home Maker
6. Retired or Disabled
7. Unemployed: Actively looking for work
8. Unemployed: Not looking for work
9. Unemployed: Volunteer work
10. 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)
1. No
2. 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?
1. No
2. 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)
1. No
2. Yes
During the past 6 months, did you receive any of the following public assistance?
1. Temporary Aid to Needy Families – TANF (welfare assistance for people with children)
2. General Assistance – GA
(welfare assistance for people without children)
3. SSI or Disability Insurance (Social Security Disability)
4. Food Stamps or WIC
5. 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 |Past 30 |Past 31-60 |past 61-90|
|following sources in the? Sources |days |days |days |
|SSI/SSD/SSA |[pic] |[pic] |[pic] |
|Other benefits such as welfare, veteran's, |[pic] |[pic] |[pic] |
|worker's compensation | | | |
|Food stamps |[pic] |[pic] |[pic] |
|WIC |[pic] |[pic] |[pic] |
|Assistance from family members to buy food,|[pic] |[pic] |[pic] |
|pay rent, get medical care or other | | | |
|Rental assistance or subsidy such as |[pic] |[pic] |[pic] |
|Section 8, HUD or TAP | | | |
|Pay from work, regular or part-time jobs. |[pic] |[pic] |[pic] |
|This does not include vocational | | | |
|rehabilitation or stipend work. | | | |
|Pay from vocational program or stipend |[pic] |[pic] |[pic] |
|work(This includes pay from a sheltered | | | |
|job, which is working in a job along with | | | |
|other persons with disabilities) | | | |
|Income from illegal activities such a s sex|[pic] |[pic] |[pic] |
|for money, dealing drugs, or other | | | |
|Other income such as panhandling, picking |[pic] |[pic] |[pic] |
|up returnable cans or bottles("canning") or| | | |
|selling crafts | | | |
|Child support payments. |[pic] |[pic] |[pic] |
|Specify: [pic] | | | |
|Other income not covered above. |[pic] |[pic] |[pic] |
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?
1. Excellent
2. Very Good
3. Good
4. Fair
5. 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. Don’t 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.]
1. No
2. Yes
Have you ever had any of the following health problems?
|Hepatitis |Chlamydia |Syphilis |Gonorrhea |
|Herpes |Pelvic Inflammatory |HIV+ |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]
1. Yes
2. No
Do you receive a pension for a physical disability?
[From any source such as the VA, social security, or workman’s compensation]
1. No
2. 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?
1. Yes
2. 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 (Cont’d)
How many times in your life have you had alcohol DT’s?
[NOTE: DT’s (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?
1. No Legal Problem
2. Case Pending
3. Drug Court
4. Probation
5. Parole
6. DWI License Suspension
7. Jail/Prison Inmate
8. DYFS or Family Court
9. 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?
1. No
2. 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?
1. Never Married
2. Married
3. Widowed
4. Separated
5. Divorced
If not “married”: Are you currently living with a significant other?
1. No
2. Yes
Are you satisfied with your current marital status?
1. No
2. Don’t Know/Indifferent
3. Yes
Check all the people you usually lived with in the past three years
(Check al that apply)
1. Spouse/Sex Partner
2. Children
3. Parents
4. Other Family
5. Friends
6. Alone
7. 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]
1. No
2. Don’t Know/ Indifferent
3. 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?
1. No
2. Yes
Do you have an active case with DYFS?
1. No
2. Yes
- Continue on “Insert 2”
Do you live with anyone who has a current alcohol problem?
1. No
2. Yes
Do you live with anyone who uses illegal drugs or non-prescribed
drugs illegally?
1. No
2. Yes
Did anyone physically abuse you or cause you physical harm:
In your life?
1. No
2. Yes
in the past 30 days?
1. No
2. Yes
Did anyone ever force sexual advances or sexual acts on you:
in your life?
1. No
2. Yes
in the past 30 days?
1. No
2. 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?
1. No
2. 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?
1. No
2. Yes
in the past 30 days?
1. No
2. 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?
1. No
2. Yes
in the past 30 days?
1. No
2. 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?
1. No
2. Yes
in the past 30 days?
1. No
2. 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?
1. No
2. 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?
1. No
2. Yes
in the past 30 days?
1. No
2. 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?
1. No
2. Yes
in the past 30 days?
1. No
2. Yes
Have you attempted suicide:
in your life?
1. No
2. Yes
in the past 30 days?
1. No
2. 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?
1. No
2. Yes
in the past 30 days?
1. No
2. 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?
1. I have NEVER used needles
2. I have NOT used needles in the past 6 months
3. I used a new needle EACH TIME I injected drugs in the past 6 months
4. I always cleaned my needle with BLEACH just BEFORE I injected drugs in the past 6 months
5. I SOMETIMES cleaned my needles with BLEACH just BEFORE I injected drugs in the past 6 months
6. 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)
1. 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?
1. No
2. Yes
If yes, did you get your results?
1. No/Never
2. Yes with all tests
3. Yes with some of the tests
Have you ever been tested for Hepatitis?
1. No
2. Yes
If yes, did you get your results?
1. No/Never
2. Yes with all tests
3. Yes with some of the tests
……… End of Assessment (ASI)………...
BioPsychoSocial
Counselor Name:
Date:
Primary 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/Sniffng
3. Smoking
4. 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 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
4. 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
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
4. 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 at First Use
Date of Last Use
Fourth 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
4. 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 at First Use
Date of Last Use
_______
Fifth 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
4. 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 at First Use
Date of Last Use
_______
Sixth 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
4. 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 at First Use
Date of Last Use
Seventh 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
4. 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 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 |No Tx. Necessary |Slightly |Moderately |Considerably |Extremely |
|patient’s… | | | | | |
|Need for employment |[pic] |[pic] |[pic] |[pic] |[pic] |
|counseling? |[pic] |[pic] |[pic] |[pic] |[pic] |
|Need for medical |[pic] |[pic] |[pic] |[pic] |[pic] |
|Treatment? |[pic] |[pic] |[pic] |[pic] |[pic] |
|Need for alcohol abuse |[pic] |[pic] |[pic] |[pic] |[pic] |
|treatment? |[pic] |[pic] |[pic] |[pic] |[pic] |
|Need for drug abuse |[pic] |[pic] |[pic] |[pic] |[pic] |
|Treatment? |[pic] |[pic] |[pic] |[pic] |[pic] |
|Need for legal services or |[pic] |[pic] |[pic] |[pic] |[pic] |
|counseling? |[pic] |[pic] |[pic] |[pic] |[pic] |
|Need for family and/or social|[pic] |[pic] |[pic] |[pic] |[pic] |
|counseling? |[pic] |[pic] |[pic] |[pic] |[pic] |
|Need for psychological and/or|[pic] |[pic] |[pic] |[pic] |[pic] |
|emotional counseling? |[pic] |[pic] |[pic] |[pic] |[pic] |
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. Assesment Date: __________________
Ineligible for Treatment Due to:
Acute Medical Problems
Active infectious disease such as TB, Hepatitis A, B, C
Acute Psychiatric Problem
Has Another Special Needs
Client has no major substance problem that impaired social, legal or medical status
Referred to SAI
Other, (If other) Specify:
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