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Assessment Form
Date
(Required)
MM slash DD slash YYYY
Personal Contact Information
First Name
(Required)
Middle Name
Last Name
(Required)
Nickname
Address
(Required)
City
(Required)
State
(Required)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Nebraska
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New Hampshire
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New York
North Carolina
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
(Required)
Phone Number
(Required)
Email
(Required)
Emergency Contact
(Required)
Phone number
(Required)
Usage Details
Substances
(Required)
Opiates
Cocaine/Crack
Marijuana
Benzodiazepines
Amphetamines
Alcohol
Check appropriate ones
DOC
(Required)
Oral
Intravenous
Intranasal
Inhalation
Check appropriate ones
Amount per day
(Required)
Frequency per day
(Required)
Date of last use
(Required)
MM slash DD slash YYYY
Year of first use
(Required)
Onset of addiction (Year)
(Required)
Days used out of 30 days:
(Required)
Please enter a number from
1
to
30
.
Withdrawal Symptoms
Diaphoresis
Current
Usually
Never
Anxiety
Current
Usually
Never
Agitation
Current
Usually
Never
Tremors
Current
Usually
Never
Diarrhea
Current
Usually
Never
Dehydration
Current
Usually
Never
Vomiting
Current
Usually
Never
Nausea
Current
Usually
Never
Muscle spasms
Current
Usually
Never
Body aches
Current
Usually
Never
Muscle cramps
Current
Usually
Never
Seizures
Current
Usually
Never
Restlessness
Current
Usually
Never
Insomnia
Current
Usually
Never
Abdominal cramps
Current
Usually
Never
Delirium tremors
Current
Usually
Never
Elevated heart rate
Current
Usually
Never
Elevated blood pressure
Current
Usually
Never
Physical weakness
Current
Usually
Never
Audio, visual, tactile hallucinations
Current
Usually
Never
Overdose and Treatment History
How many overdoses?
Please enter a number from
0
to
100
.
Overdose Dates
Overdose Causes
Previous Treatment(s)
Family History
Do any family members have a drug or alcohol problem?
(Required)
YES
NO
Who else has a drug or alcohol problem?
Do any family members have psychiatric or mental health issues?
(Required)
YES
NO
Who else has psychiatric or mental health issues?
How many children do you have?
(Required)
Children's Ages
Are there any family problems?
(Required)
YES
NO
Overall assessment of your family problems:
MILD
MODERATE
SEVERE
Family Problem Details
Negative Effects of Addiction
Has your addiction created problems with your employment?
(Required)
YES
NO
Employment Problems Details
Examples: missed days/late/write ups
Have you had any legal problems due to alcohol and/or other drugs?
(Required)
YES
NO
Legal Problems Details
Examples: DWI; DUI; charges while intoxicated; assault
Psychological Issues
Have you been abused?:
emotionally
mentally
physically
sexually
List of Psychiatric DX
(Required)
Overall assessment of substance use problems:
(Required)
MILD
MODERATE
SEVERE
Overall assessment of mental health problems:
(Required)
MILD
MODERATE
SEVERE
Medical Issues
List of Medical Issues
(Required)
Ambulatory Issues
(Required)
Can patient walk? Do they use use any assistive devices (like a wheelchair, cane, etc)?
Overall assessment of medical problems:
(Required)
MILD
MODERATE
SEVERE
Medication(s):
(Required)
Susbstance Dependence Assessment
DSM V CRITERIA FOR SUBSTANCE DEPENDENCE:
(Required)
(Three or more of the following criteria must have occurred at any time in the same 12-month period)
Tolerance
Withdrawal
Substance is taken in larger amounts or over a longer period than was intended
There is a persistent desire or unsuccessful efforts to cut down or control use
A great deal of time is spent in activities necessary to obtain OR use the substance
Important social, occupational or recreational activities are given up or reduced
The substance use is continued in spite of recurrent negative outcomes
Diagnostic Impressions
(approved licensed professionals only)
Substance Use Disorder:
(Required)
MILD
MODERATE
SEVERE
DSM - V code:
substance use disorder
Stressors:
(Required)
Chronic addiction
Problems with primary support group
Poor social environment
Educational/occupational problems
Financial stressors
Limited resources
Legal problems
Poor access to medical/mental health services
Housing problems
Other Psychosocial/Environmental Problems:
Information Sources
INFORMATION RESOURCES:
(Required)
Client Disclosure
Family Members
Spouse
Significant
Employer
Friends
Records or Reports from a previous Treatment Facility
Other
Other source:
Counselor
Date
MM slash DD slash YYYY
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