Form Dmhas - Substance Use Questionnaire October 2015 (Page 2 of 2) in pdf

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.

9) Describe any recent or increase in stressors and what interventions were implemented.

Family issues - Interventions: ________________________________________________________________________

Employment issues - Interventions: ___________________________________________________________________

Health issues - Interventions: ________________________________________________________________________

Legal issues - Interventions: _________________________________________________________________________

Family issues - Interventions: ________________________________________________________________________

Housing issues - Interventions: _______________________________________________________________________

Loss of relationship - Interventions: ___________________________________________________________________

Other, specify ____________________ - Interventions: ___________________________________________________

10) Describe any evidence of recent increased substance use within the past 30 days.

No evidence noted

Positive UDS

Recent relapse

Other, specify ___________________________________

11) Did the consumer have a relapse prevention plan?

Yes

No. If yes, was it implemented?

Yes

No. If not, please explain:

___________________________________________________________________________________________________

12) Describe any communication between this program and other providers (substance use, mental health, primary care,

etc.).

___________________________________________________________________________________________________

DMHAS Appendix 2: Substance Use Questionnaire

10-2015

Form Dmhas - Substance Use Questionnaire October 2015 Page 2