Chemical Dependency Evaluation Interview Form (Page 7 of 7) in pdf

Chemical Dependency Evaluation Interview Form Page 7

Who lives in the home:

Religion of family origin:

Current Religion:

Active?

Social History

Main leisure pursuits:

Which of these usually includes alcohol/drug use: (Please indicate whether alcohol/drugs or both)

Number of close friends:

How often do you see them:

What types of things do you do together:

Do they include drinking/using:

Do you have people to talk to and share with:

_________Family

_________Other

_________Religious

_________Employment/EAP

_________Groups

I. Psychiatric Status - Behavioral History

Have you ever been to counseling before? If yes where, for how long and what for?

Have you ever been on any medications? For what reason, for how long and the dosage?

Were there any side effects from the medication?

Have you ever experienced the following? (If yes please describe)

Problems sleeping:

Crying spells:

Appetite disturbance:

Rapid weight loss or gain:

Difficulty in concentration:

Feeling of depression:

Suicidal thoughts:

When:

Most recent:

Suicidal attempts:

When:

How:

Repetitive troubling thoughts:

Impulsiveness

Inability to work due to “stress”

Heard voices or other unusual events:

Chemical Dependency Evaluation Interview Form Page 7