Please complete this form as best as you can and submit prior to your intake appointment. Please know this form is reviewed during the intake and if not complete prior to your scheduled intake appointment, the appointment will be delayed and may have to be rescheduled.
List any previous psychiatric or substance abuse evaluations, counseling or hospitalizations.
Diagnosis (if known)
List any previous psychiatric medication therapy.
List all medications that you are currently taking (please continue in Part 18 if more space required):
Name of Drug
Amount Taken (dose)
(If experiencing pain, please score your pain on a 10 point scale where 0 = no pain and 10 = worst pain imaginable)
Please check the box that most applies to you.
Monthly or Less
2-4 Times Monthly
2-3 Times Weekly
4+ Time Weekly
1. How often do you have a drink containing alcohol?
4+ Times Weekly
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
Daily or Close
3. How often do you have six or more drinks on one occasion?
4. How often during the last year have you found that you were not able to stop drinking once you had started?
5. How often during the last year have you failed to do what was normally expected of you because of drinking?
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
8. How often during the last year have you been unable to remember what happened the night before because of drinking?
Yes, but not in the last year
Yes, during the last year
9. Have you or someone else been injured as a result of your drinking?
Yes, but not in last year
10. Has anyone been concerned about your drinking or suggested that you should cut down
What do you smoke or use?
Who raised you?
Both ParentsMotherFatherOther FamilyFoster Parent(s)Adoptive Parent(s)Other
What was it like in your childhood home?
Did you have any developmental delays or problems?
Have you ever been physically, sexually or emotionally abused?
If married, are you currently having any stressors or problems in your marriage?
Have you been married previously?
Do you have any concerns about domestic violence or abuse?
Have you or any of your spouses ever been referred to any agency such as Child Protective Services?
Please list all your children: (continue below, if needed)
Biological or Stepchild?
Does this child currently reside with you?
Does anyone else reside in your household?
Are you having any problems with your children?
Are there any firearms in your home?
Is there any history of domestic violence in your home?
Do you have a history of suicidal or self-destructive thoughts or behaviors?
Do you have a history of homicidal (harm to others) thoughts or behaviors?
Do you have any other safety concerns at this time?
Do you have someone to talk to when you have a problem?
Is there someone you would ask for help if you needed it?
Are you geographically separated from family and friends?
Are you having trouble with your relationships with family, friends or coworkers?
Have you recently withdrawn from family or friends?
Do you belong to any groups or organizations that are supportive and helpful to you?
How much is your religion or spirituality a source of strength or comfort to you?
Not at allNot very muchSomewhatQuite a bitA great deal
How much is your spiritual community a source of support to you?
Do you have any religious, spiritual or cultural practices that your provider needs to be aware of during treatment?
If "Yes," please explain:
Do you currently have any financial problems?