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:

-----------------------

$

$

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download