Client Bio-Psycho-Social Intake Form

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(800)-213-ETRS | Wayne County: 734-462-3096 | Oakland County: 248-399-2600

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About
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Client Bio-Psycho-Social Intake

Today's Date

MM slash DD slash YYYY

Identifying Information

Case/MDOCH#

Name

First Middle Last

DOB

MM slash DD slash YYYY

Age

Sex

Male

Female

Other

Phone

Email

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

MM slash DD slash YYYY

Is treatment part of your sentencing?

Yes

No

Type of offense

Date of offense:

MM slash DD slash YYYY

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

No

If yes, please explain.

List Prior Arrests and Convictions

Facility	Date	Diagnosis	Outcome	Type of care	Actions

There are no prior arrests and convictions.

Maximum number of prior arrests and convictions reached.

Education/Employment

Circle Highest School Grade Completed

6

7

8

9

10

11

12

Year of Graduation

Did you obtain GED?

Yes

No

College

Trade School

Are you employed?

Yes

No

Employment

Full Time

Part Time

Occupation

Present Employer

Last Employer

Do you receive Social Security benefits/Disability or SI?

Yes

No

Do you receive health benefits?

Yes

No

Health Status and History

Check al 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

Substance Type	Age When First Tried	Age of Regular Use	Precont Ucs How much/how often?	Maximum amount used at 1sitting	Actions

There are no any past hospitalizations and treatments.

Maximum number of any past hospitalizations and treatments reached.

Interviewers Notes

Personal and Emotional Status

Check al that apply to your current health status

Calm

Upset

Confused

Hyper

Bored/Tired

Worried/Stressed

Check al 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 therapist

If yes, name of provider

May we discuss your case with them?

Yes

No

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

Marital/Relationship History

Current: Marital Status

Never Married

Married

Life Partner

Divorced

Widowed

Marriages

Divorces

Reasons for divorce

Ages of children

Who currently lives ni 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?

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 ni 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/History

Branch of Service

Rank/Role/Responsibility

Overseas Deployment

Yes

No

Stateside

Yes

No

Combat

Yes

No

Type of Discharge

Honorable

Dishonorable

Other

VA Assistance?

Yes

No

Interviewers Notes

Consequences of Substance Use

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

Yes

No

Who

Their comments

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

Yes

No

If yes, when and why

Have 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 drugging?

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, explain

Have 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, explain

What percentage of your friends drink/use drugs?

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

Yes

No

If yes, explain

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

Yes

No

When and for how long

Why at that time

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

Living Arrangement

Job Situation

Relationships

Leisure Activities

ETRS Substance Use Assessment

List of substance use

Substance Type	Age When First Tried	Age of Regular Use	Maximum amount used at 1sitting	Precont Ucs How much/how often?	Date last used	Use in last 24 hours	Use in last 48 hours	Actions

There are no substances use.

Maximum number of substances use reached.

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