Client Intake Today's Date MM slash DD slash YYYY Identifying InformationCase/MDOCH#Name First Middle Last DOB MM slash DD slash YYYY AgeSex Male Female Other PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Emergency contact personPhoneLegal InformationReferring courtProbation Officer:PhoneLegal Status On probation On parole Awaiting trial/pre-trial/sentencing Probation/Parole End Date MM slash DD slash YYYY Is treatment part of your sentencing? Yes No Type of offenseDate of offense: MM slash DD slash YYYY BAC %State your version of the incident that led to your arrestHave you had a positive alcohol/drug test while on probation/parole? Yes No If yes, please explain.Prior Arrests and ConvictionsDate MM slash DD slash YYYY ChargeCitySentenceDrug/Alcohol Related? Yes No Date MM slash DD slash YYYY ChargeCitySentenceDrug/Alcohol Related? Yes No DateChargeCitySentenceDrug/Alcohol Related? Yes No DateChargeCitySentenceDrug/Alcohol Related? Yes No Education/EmploymentCircle Highest School Grade Completed 6 7 8 9 10 11 12 Year of GraduationDid you obtain GED? Yes No CollegeTrade SchoolAre you employed? Yes No Employment Full Time Part Time OccupationPresent EmployerLast EmployerDo you receive Social Security benefits/Disability or SI? Yes No Do you receive health benefits? Yes No Health Status and HistoryCheck all that apply to your current health status Excellent Good Fair Poor Stable Doctor's NameDr. PhoneDate of last physical examOutcomeAny immediate health concerns?Current illnesses and medications takenList any past hospitalizations and treatments including those for alcohol or other substance useFacilityDate MM slash DD slash YYYY Diagnosis & TreatmentOutcomeFacilityDate MM slash DD slash YYYY Diagnosis & TreatmentOutcomeFacilityDate MM slash DD slash YYYY Diagnosis & TreatmentOutcomeInterviewers NotesPersonal and Emotional StatusCheck 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 No Are you interested in a referral for counseling or support? Yes No Are you currently receiving mental health services? Yes No Name of therapistIf yes, name of providerMay we discuss your case with them? Yes No If yes, please request a release of information to be signed.Marital/Relationship HistoryCurrent: Marital Status Never Married Married Life Partner Divorced Widowed MarriagesDivorcesReasons for divorceAges of childrenWho 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 OriginWho raised you? Both Parents Mother Only Father Only Relative Other 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 No If yes, whom?Military Service/HistoryBranch of ServiceRank/Role/ResponsibilityOverseas Deployment Yes No Stateside Yes No Combat Yes No Type of Discharge Honorable Dishonorable Other VA Assistance? Yes No Interviewers NotesConsequences of Substance UseHas anyone ever expressed concern about your alcohol/drug use? Yes No WhoTheir commentsHave you ever changed or tried to limit your alcohol/drug use? Yes No If yes, when and whyHave you ever used more or for longer than you intended? Yes No 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 No If yes, explainHave you ever gotten sick after discontinuing drinking/drug use? Yes No While drinking or using drugs, do you ever behave in ways that would normally be unacceptable to you? Yes No If yes, explainWhat percentage of your friends drink/use drugs?While drinking or using other drugs, have you ever been suicidal or homicidal? Yes No If yes, explainHave there been periods of time when you chose to be alcohol and drug free? Yes No When and for how longWhy at that timeDescribe any changes that might have occurred in the last year in yourLiving ArrangementJob SituationRelationshipsLeisure ActivitiesETRS Substance Use AssessmentIn the past have you used Alcohol? Yes No Alcohol Use InfoAge when First TriedAge of Regular UseMaximum amount used at one sitingPresent Use: How often/how much?Date Last UsedAmount used in last 24 hrsAmount used in last 48 hrsIn the past have you used Sedatives (sleeping pills, benzodiazepines/Xanax/Klonopin, tranquilizers)? Yes No Sedatives Use InfoAge when First TriedAge of Regular UseMaximum amount used at one sitingPresent Use: How often/how much?Date Last UsedAmount used in last 24 hrsAmount used in last 48 hrsIn the past have you used Stimulants (amphetamines, cocaine, crack, diet pills, methamphetamine)? Yes No Stimulants Use InfoAge when First TriedAge of Regular UseMaximum amount used at one sitingPresent Use: How often/how much?Date Last UsedAmount used in last 24 hrsAmount used in last 48 hrsIn the past have you used Hallucinogens (LSD, mushrooms, mescaline, PCP, peyote)? Yes No Hallucinogens Use InfoAge when First TriedAge of Regular UseMaximum amount used at one sitingPresent Use: How often/how much?Date Last UsedAmount used in last 24 hrsAmount used in last 48 hrsIn the past have you used Marijuana/Hashish/Wax? Yes No Marijuana/Hashish/Wax Use InfoAge when First TriedAge of Regular UseMaximum amount used at one sitingPresent Use: How often/how much?Date Last UsedAmount used in last 24 hrsAmount used in last 48 hrsIn the past have you used Narcotics (morphine, codeine, heroin, Norco, Vicodin, Darvon, Percocet, Oxycodone)? Yes No Narcotics Use InfoAge when First TriedAge of Regular UseMaximum amount used at one sitingPresent Use: How often/how much?Date Last UsedAmount used in last 24 hrsAmount used in last 48 hrsIn the past have you used Prescription & Over-the-Counter Drugs (cough syrup, diet aids, sleeping aids, decongestants, etc.)? Yes No Prescription & Over-the-Counter Drugs Use InfoAge when First TriedAge of Regular UseMaximum amount used at one sitingPresent Use: How often/how much?Date Last UsedAmount used in last 24 hrsAmount used in last 48 hrsIn the past have you used Club drugs (ecstasy, ketamine, GHB, Rohypnol)? Yes No Club Drugs Use InfoAge when First TriedAge of Regular UseMaximum amount used at one sitingPresent Use: How often/how much?Date Last UsedAmount used in last 24 hrsAmount used in last 48 hrsIn the past have you used Other Drugs (steroids, inhalants, glue, gas, whipits, etc.)? Yes No Other Drugs Use InfoAge when First TriedAge of Regular UseMaximum amount used at one sitingPresent Use: How often/how much?Date Last UsedAmount used in last 24 hrsAmount used in last 48 hrsIn the past have you used Fentanyl/Carfentanil? Yes No Fentanyl/ Carfentanil Use InfoAge when First TriedAge of Regular UseMaximum amount used at one sitingPresent Use: How often/how much?Date Last UsedAmount used in last 24 hrsAmount used in last 48 hrsMAST (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 No 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 No Does your partner, a parent, or other near relative ever worry or complain about your drinking? Yes No Can you stop drinking without a struggle after one or two drinks? Yes No Do you ever feel guilty about your drinking? Yes No Do friends or relatives think you are a normal drinker? Yes No Are you able to stop drinking when you want to? Yes No Have you ever attended a meeting of Alcoholics Anonymous (AA) because of your own drinking? Yes No Have you ever gotten into physical fights when drinking? Yes No Has your drinking ever created problems between you and your partner, a parent, or other near relative? Yes No Has your partner, a parent, or other near relative ever gone to anyone for help about your drinking? Yes No Have you ever lost friends or partners because of your drinking? Yes No Have you ever gotten into trouble at work or school because of your drinking? Yes No Have you ever lost a job because of drinking? Yes No Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking? Yes No Do you drink before noon fairly often? Yes No Have you ever been told you have liver trouble (cirrhosis)? Yes No 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 No How many times?Have you ever gone to anyone for help about your drinking? Yes No Have you ever been in a hospital because of your drinking? Yes No 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 No 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 No Have you ever been arrested for drunken driving driving while intoxicated, or driving under the influence of alcoholic beverages? Yes No How many times?Have you ever been arrested, even for a few hours, because of other drunken behavior? Yes No 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 ... HONESTYHave you used drugs other than those required for medical reasons? Yes No Have you ever abused prescription drugs? Yes No Do you abuse more than one drug at a time? Yes No Can you get through the week without using drugs (other than those used for medical reasons)? Yes No Are you always able to stop using drugs when you want to? Yes No Do you abuse drugs on a continuous basis? Yes No Do you try to limit your drug use to certain situations? Yes No Have you had "blackouts" or "flashbacks" as a result of drug use? Yes No Do you ever feel bad about your drug abuse? Yes No Does your spouse (or parents) ever complain about your involvement with drugs? Yes No Do your friends or relatives know or suspect you abuse drugs? Yes No Has drug abuse ever created problems between you and your spouse/partner? Yes No Has any family member ever sought help for problems related to your drug use? Yes No Have you ever lost friends because of your use of drugs? Yes No Have you ever neglected your family or missed work because of your drug use? Yes No Have you ever been in trouble at work because of drug abuse? Yes No Have you ever lost a job because of drug abuse? Yes No Have you gotten into fights when under the influence of drugs? Yes No Have you ever been arrested because of unusual behavior while under the influence of drugs? Yes No Have you ever been arrested for driving while under the influence of drugs? Yes No Have you engaged in illegal activities to obtain drugs? Yes No Have you ever been arrested for possession of illegal drugs? Yes No Have you ever experienced withdrawal symptoms as a result of heavy drug intake? Yes No Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, or bleeding)? Yes No Have you ever gone to anyone for help for a drug problem? Yes No Have you ever been in the hospital for medical problems related to your drug use? Yes No Have you ever been involved in a treatment program specifically related to drug use? Yes No Have you ever been treated as an outpatient for problems related to drug abuse? Yes No Audit QuestionnaireHow 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? 1-2 3-4 5-6 7-9 10+ 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 Δ
