Client Intake Form

NOTE: This form may take you an hour or more to complete. Please plan accordingly.

Client Intake

Today's Date

Identifying Information

Case/MDOCH#

Name

First Middle Last

DOB

Age

Sex

Male

Female

Other

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency contact person

Phone

Legal Information

Referring court

Probation Officer:

Phone

Legal Status

On probation

On parole

Awaiting trial/pre-trial/sentencing

Probation/Parole End Date

Is treatment part of your sentencing?

Yes

Type of offense

Date of offense:

BAC %

State your version of the incident that led to your arrest

Have you had a positive alcohol/drug test while on probation/parole?

Yes

If yes, please explain.

Prior Arrests and Convictions

Date

Charge

City

Sentence

Drug/Alcohol Related?

Yes

Date

Charge

City

Sentence

Drug/Alcohol Related?

Yes

Date

Charge

City

Sentence

Drug/Alcohol Related?

Yes

Date

Charge

City

Sentence

Drug/Alcohol Related?

Yes

Education/Employment

Circle Highest School Grade Completed

Year of Graduation

Did you obtain GED?

Yes

College

Trade School

Are you employed?

Yes

Employment

Full Time

Part Time

Occupation

Present Employer

Last Employer

Do you receive Social Security benefits/Disability or SI?

Yes

Do you receive health benefits?

Yes

Health Status and History

Check all that apply to your current health status

Excellent

Good

Fair

Poor

Stable

Doctor's Name

Dr. Phone

Date of last physical exam

Outcome

Any immediate health concerns?

Current illnesses and medications taken

List any past hospitalizations and treatments including those for alcohol or other substance use

Facility

Date

Diagnosis & Treatment

Outcome

Facility

Date

Diagnosis & Treatment

Outcome

Facility

Date

Diagnosis & Treatment

Outcome

Interviewers Notes

Personal and Emotional Status

Check all that apply to your current health status

Calm

Upset

Confused

Hyper

Bored/Tired

Worried/Stressed

Check all that apply to your current health status

Anxiousness

Anger/Hostility

Depression

Fears

Guilt

Low Self-Worth

Mood Swings

Fears Poor sleep/appetite

Have you ever had suicidal thoughts?

Yes

Are you interested in a referral for counseling or support?

Yes

Are you currently receiving mental health services?

Yes

Name of therapist

If yes, name of provider

May we discuss your case with them?

Yes

If yes, please request a release of information to be signed.

Marital/Relationship History

Current: Marital Status

Marriages

Divorces

Reasons for divorce

Ages of children

Who currently lives in your household with you?

Indicate any areas of conflict with your relationship partner

Money

Friends

Jobs

In-laws

Sex

Alcohol/Drugs

Legal Problems

Communication

Domestic Violence

Family of Origin

Who raised you?

How was/is your relationship with your parents?

Good

Poor

How many siblings do you have?

Who are you closest to in your family?

Do you have any other family members who have experienced any alcohol or drug-related problems?

Yes

If yes, whom?

Military Service/History

Branch of Service

Rank/Role/Responsibility

Overseas Deployment

Yes

Stateside

Yes

Combat

Yes

Type of Discharge

Honorable

Dishonorable

Other

VA Assistance?

Yes

Interviewers Notes

Consequences of Substance Use

Has anyone ever expressed concern about your alcohol/drug use?

Yes

Who

Their comments

Have you ever changed or tried to limit your alcohol/drug use?

Yes

If yes, when and why

Have you ever used more or for longer than you intended?

Yes

How many drinks does it take to make you feel intoxicated?

How would you describe your tolerance to alcohol?

Have you ever forgotten something or had periods of time you couldn't account for when drinking or using drugs?

What undesirable physical reactions, if any, have you had while using or after use?

Have you ever overdosed or come close to an overdose?

Yes

If yes, explain

Have you ever gotten sick after discontinuing drinking/drug use?

Yes

While drinking or using drugs, do you ever behave in ways that would normally be unacceptable to you?

Yes

If yes, explain

What percentage of your friends drink/use drugs?

While drinking or using other drugs, have you ever been suicidal or homicidal?

Yes

If yes, explain

Have there been periods of time when you chose to be alcohol and drug free?

Yes

When and for how long

Why at that time

Describe any changes that might have occurred in the last year in your

Maximum amount used at one siting

Present Use: How often/how much?

Date Last Used

Amount used in last 24 hrs

Amount used in last 48 hrs

MAST (Alcohol Use Screening Test)

Persons, sometimes unknowingly, deceive themselves about their personal status in the use of alcohol. This may occur because they think only in terms of how MUCH, how OFTEN, or WHAT they are drinking. A person by answering the following questions honestly, can have a better understanding of their position with alcohol.

Instructions: Check the word "YES" or "NO" which you honestly feel describes your position in regard to each question below. The key to answering the questions: HONESTY

In your lifetime...

Do you feel you are a normal drinker? (By normal, we mean you drink less than or as much as most other people)

Yes

Have you ever awakened the morning after some drinking the night before and found that you couldn't remember a part of the evening before?

Yes

Does your partner, a parent, or other near relative ever worry or complain about your drinking?

Yes

Can you stop drinking without a struggle after one or two drinks?

Yes

Do you ever feel guilty about your drinking?

Yes

Do friends or relatives think you are a normal drinker?

Yes

Are you able to stop drinking when you want to?

Yes

Have you ever attended a meeting of Alcoholics Anonymous (AA) because of your own drinking?

Yes

Have you ever gotten into physical fights when drinking?

Yes

Has your drinking ever created problems between you and your partner, a parent, or other near relative?

Yes

Has your partner, a parent, or other near relative ever gone to anyone for help about your drinking?

Yes

Have you ever lost friends or partners because of your drinking?

Yes

Have you ever gotten into trouble at work or school because of your drinking?

Yes

Have you ever lost a job because of drinking?

Yes

Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?

Yes

Do you drink before noon fairly often?

Yes

Have you ever been told you have liver trouble (cirrhosis)?

Yes

After heavy drinking, have you ever had delirium tremens (DTs) or severe shaking, or heard voices or seen things that weren't really there?

Yes

How many times?

Have you ever gone to anyone for help about your drinking?

Yes

Have you ever been in a hospital because of your drinking?

Yes

Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where your drinking was part of the problem that resulted in hospitalization?

Yes

Have you ever been seen at a psychiatric or mental health clinic or gone to any doctor, social worker, or clergy member for help with any emotional problem where your drinking was part of the problem?

Yes

Have you ever been arrested for drunken driving driving while intoxicated, or driving under the influence of alcoholic beverages?

Yes

How many times?

Have you ever been arrested, even for a few hours, because of other drunken behavior?

Yes

How many times?

DAST (Drug Abuse Screening Test)

Instructions: Check the word "yes" or "no", which you honestly feel describes your position in regard to each of the questions below. The key to answering the questions ... HONESTY

Have you used drugs other than those required for medical reasons?

Yes

Have you ever abused prescription drugs?

Yes

Do you abuse more than one drug at a time?

Yes

Can you get through the week without using drugs (other than those used for medical reasons)?

Yes

Are you always able to stop using drugs when you want to?

Yes

Do you abuse drugs on a continuous basis?

Yes

Do you try to limit your drug use to certain situations?

Yes

Have you had "blackouts" or "flashbacks" as a result of drug use?

Yes

Do you ever feel bad about your drug abuse?

Yes

Does your spouse (or parents) ever complain about your involvement with drugs?

Yes

Do your friends or relatives know or suspect you abuse drugs?

Yes

Has drug abuse ever created problems between you and your spouse/partner?

Yes

Has any family member ever sought help for problems related to your drug use?

Yes

Have you ever lost friends because of your use of drugs?

Yes

Have you ever neglected your family or missed work because of your drug use?

Yes

Have you ever been in trouble at work because of drug abuse?

Yes

Have you ever lost a job because of drug abuse?

Yes

Have you gotten into fights when under the influence of drugs?

Yes

Have you ever been arrested because of unusual behavior while under the influence of drugs?

Yes

Have you ever been arrested for driving while under the influence of drugs?

Yes

Have you engaged in illegal activities to obtain drugs?

Yes

Have you ever been arrested for possession of illegal drugs?

Yes

Have you ever experienced withdrawal symptoms as a result of heavy drug intake?

Yes

Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, or bleeding)?

Yes

Have you ever gone to anyone for help for a drug problem?

Yes

Have you ever been in the hospital for medical problems related to your drug use?

Yes

Have you ever been involved in a treatment program specifically related to drug use?

Yes

Have you ever been treated as an outpatient for problems related to drug abuse?

Yes

Audit Questionnaire

How often do you have a drink containing alcohol?

Never

Monthly or less often

Few times per month

Few times per week

4 or more times per week

How many standard drinks containing alcohol do you have on a typical day when drinking?

How often do you have six or more drinks on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

During the past year, how often have you found that you were not able to stop drinking once you had started?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

During the past year, how often have you failed to do what was normally expected of you because of drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

During the past year, how often have you had a feeling of guilt or remorse after drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

During the past year, have you been unable to remember what happened the night before because you had been drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you or someone else been injured as a result of your drinking?

Never

Yes, but not in the past year

Yes, during the past year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?

Never

Yes, but not in the past year

Yes, during the past year

By clicking “I Agree”, I hereby authorize and consent to the use and disclosure of my protected health information (“PHI”) in accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I understand that this authorization permits ETRS Michigan, its staff, agents, contractors, and affiliated providers, to use and disclose my health information for purposes including, but not limited to: • Evaluation and assessment • Treatment planning and coordination of care • Communication with referral sources, probation/parole officers, attorneys, courts, and other authorized parties • Billing, payment, and healthcare operations. This authorization shall remain in effect for one (1) year from the date of electronic acknowledgment unless revoked earlier in writing.(Required)

I agree