Various models of substance abuse prevention, intervention, and rehabilitation are available for the delivery of support services for justice-involved individuals with addiction and substance abuse is

Various models of substance abuse prevention, intervention, and rehabilitation are available for the delivery of support services for justice-involved individuals with addiction and substance abuse is
CPSS/420 v2 Intake Assessment Form Intake Instructions Intake staff shall review each completed intake assessment completed for each program participant. The intake assessment may help identify a program participant’s treatment needs, but it is the responsibility of staff to gather additional information in the following areas: Social supports, economic resources (including health insurance or Medicaid availability), the program participant’s family history, education, employment history, criminal history, legal status, medical history, alcohol use and other drug use history, and finally previous treatment programs. Intake assessments should include the evaluation of substance use disorders; the evaluation of alcohol use disorders, and the assessment of treatment needs. This information is utilized to create client driven, clinically supported treatment plans that are SMART (Specific, Measurable, Attainable, Realist and Timelined) Client Information Client’s First Name: Client’s Last Name: Date of Birth: Insurance Type: Client’s Preferred Name: Admission Date: Emergency Contact Information Emergency Contact: Relationship: Contact Address (Street, City, State, Zip): Contact Phone Number: Release for Emergency Contact obtained for this time period: Personal Information Sex Assigned at Birth Mention ‘Yes’ against what is relevant: Male: Female: Intersex: Gender queer: Gender non-conforming: Male to female: Female to male: Other (Specify): Unknown or declined to state: Gender Identity Mention ‘Yes’ against what is relevant: Male: Female: Intersex: Gender queer: Gender non-conforming: Male to female: Female to male: Other: Unknown or declined to state: Pronoun Preferred Mention ‘Yes’ against what is relevant: Him: Her: They: Other: Unknown: Referral Reason Why has the client been referred? Treatment counselor: Alcohol and Drug History Fill in appropriate details for each. Check if ever used: Age at first use: None or denies Current Use Current Abuse Current Dependence In Recovery Client-perceived Problem? Write Y or N Alcohol Amphetamines (Speed/Uppers, etc.) Cocaine/Crack Opiates (Heroin, Oxy, Methadone, Suboxone) Hallucinogens (LSD, Mushrooms, Ecstasy, Molly) Sleeping pills, Benzos, Valium, or similar PSP (Phencyclidine) or Designer Drugs (GHB) Inhalants (paint, gas, glue, aerosols) Marijuana, Hashish. DABS Tobacco, nicotine, vaping, chew Caffeine (energy drinks, sodas, coffee, etc.) Over the counter Other substances Complimentary alternative medication Previous Drug and/or Alcohol Treatment History: Medical History: Medical Provider Name: Phone #: Last Date of Service: Primary Physician: Other medical provider(s) Date records requested: From whom, if applicable: Relevant Medical History General Info: Baseline weight: Weight changes: BP: Mention ‘Yes’ wherever relevant Condition Cardiovascular Respiratory Genital, urinary, bladder Gastro-intestinal bowel Nervous system Musculoskeletal Gyneco logy Skin Endocrine Chest pain Hypertension Hypotension Palpitation Smoking Bronchitis Asthma COPD COVID Incontinence Nocturia UTI Retention Urgency Heartburn Diarrhea Constipation Nausea Vomiting Ulcers Pancreatitis Headache TBI/LOC Seizures Memory Concentration Back pain Broken bones Arthritis Mobility issues Pregnant STD Menopause Scar Lesion Lice Dermatitis Burns Diabetes Thyroid Significant accident Injuries Surgeries Hospitalizations Physical disability Chronic illness HIV Liver disease Write details against what is relevant: Significant accident Injuries: Surgeries: Hospitalizations: Physical disability: Chronic illness: HIV: Liver disease: Alternative healing practice/date For example, acupuncture, herbs, supplements, etc. Current/ Previous Medications (Include all prescribed, OTC, holistic/alternative remedies) Allergies/Adverse Reactions/ Sensitivities: Food: Drugs (Rx/OTC/ILLICT): Unknown: Other: Date of last physical exam: Date of last dental exam: Referral made to primary care or specialty (Yes or No. If yes, list): Additional Medical Information: Mental Health History Psychiatric Hospitalizations Yes or No: Outpatient Treatment Yes or No: Risk factors Mention ‘Yes’ against what is relevant: Aggressive/Violent Behaviors: Self-Harm: Client referred to crisis services line: Mental health disorders that are pre-existing, contribute to substance use/abuse, or have been exacerbated by substance use: Psychosocial History Family problems that are contributing to, or are exacerbated by, substance abuse. Mention ‘Yes’ against what is relevant and describe below: Arguments: Domestic violence: Family abuses alcohol/drugs: Family worried about client’s use of drugs/alcohol: Separated or divorced: Describe Problems Contributing to Substance Abuse Highest level of education completed: Employment History Client currently employed? (Yes/ No): If so, list employer and job: Problems Caused by Substance Abuse: Add “Yes” after anything substance use/abuse has caused or contributed to: Absenteeism: Tardiness: Accidents: Working while hung-over: Trouble concentrating: Decreased job performance: Consumed substances while at work: Lost job due to substance abuse: No work problem: Comments: Criminal History/Legal Status Criminal History Table Legal Status Table Other: Describe criminal justice involvement. Note: More space is provided in the Addendum Describe any relevant family involvement with criminal justice. Note: More space is provided in the Addendum Personal History Write ‘Not Applicable’ if not applicable. Client currently in a relationship? If yes, list length or other comments below: History of sexual abuse? History of physical abuse? Does client have children? If yes, list age of each below: Child 1: Child 2: Child 3: Child 4: Child 5: Describe assessed knowledge of parenting skills. Describe assessed education/knowledge of harmful effects that alcohol and drugs have on the caregiver and fetus, or caregiver and infant. List parenting skills most needed. Does client need or will client receive childcare? Answer yes or no: Client needs to access the following ancillary services which are medically necessary. Provide comments below: (Mention ‘Yes’ against what is relevant) Dental services: Social services: Community services: Educational/Vocational training: Transportation (or arranging for) to and from medically necessary treatment: Other: Specify: Clinical Formulation Instructions: Consider all information gathered in the intake assessment for the treatment plan formulation. The formulation should identify each problem that is contributing to client’s alcohol or substance use disorder. All issues identified during the intake assessment process must be listed as a problem statement on the treatment plan (SMART goals). However, some problem statements can de deferred as determined appropriate by the treatment staff. Addendum Use this area to report additional criminal justice involvement, etc. Copyright 2021 by University of Phoenix. All rights reserved.