Form Dmhas - Substance Use Questionnaire October 2015 printable pdf download

New Jersey Department of Human Services

Division of Mental Health & Addiction Services

Appendix 2: Substance Use Questionnaire

Please complete in all cases when the consumer has been diagnosed with a substance use disorder, if they are

receiving substance use treatment, if they are known to have used/abused substances in the past, if the incident is

directly related to substance use, and/or if the mention of substance use is in the narrative of the report.

NOTE: If 2a is completed Appendix 2 does not need to be completed.

Consumer Name: _____________________________________ Incident Date: _____________ UIRMS #: ________________

1) What is the specific substance use related disorder diagnosis? ________________________________________________

When was the diagnosis made? ______________________, and by whom? _____________________________________

If no diagnosis was made, please note that. __________________________

2) Has the consumer been recently discharged from a residential facility for substance use?

Yes

No. If Yes, please provide: Facility Name: _______________________________________________________,

Admission date: ________________, and Discharge date: ________________.

3) What was the consumer’s medication (psychiatric and medical - including Medication Assisted Treatment) adherence?

___________________________________________________________________________________________________

4) Were medications requiring blood levels monitored?

Yes

Not applicable

If yes, what were the results?

Within therapeutic range

Abnormal

5) What substance use interventions were listed on the consumer’s treatment plan?

Random UDS

Coping skills

Relapse triggers education

Psychotropic medications

AA/NA with sponsor

Medication-assisted Treatment

Counseling

Other, specify: __________________________________________

6) Was the consumer abstinent from all substances?

Yes

If not, what interventions were implemented? _____________________________________________________________

___________________________________________________________________________________________________

What was the date of the last urine drug screening test? __________ and what were the results?

Negative

Positive

7) Describe the use of the Prescription Monitoring Program (PMP) upon admission and/or during any other part of the

consumer’s treatment. Please explain what was done.

___________________________________________________________________________________________________

8) Describe the level of participation by the consumer with regards to the substance use interventions (e.g., compliant with

UDS, attends program, participates in group, adherent to medications, continues to use, etc.).

___________________________________________________________________________________________________

DMHAS Appendix 2: Substance Use Questionnaire

10-2015

Form Dmhas - Substance Use Questionnaire October 2015

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