Chemical Dependency - Assessment/screening Form printable pdf download

SEVEN COUNTIES SERVICES

Jefferson Alcohol & Drug Abuse Center

Name, Soc Sec #, Client ID, DOB

SCREENING – Eval

(USE BLACK PEN)

Client – please complete:

Name ________________________________________________ Date __________________________

Address ______________________________________________________________________________

Phone ________________________ SS# _______________________

Date of Birth _____________________ Age _______  Male

 Female

Emergency Contact Name _____________________________ Address ___________________________

Phone ___________________________

Race:  Caucasian  African American

 Native American  Asian  Pacific Islander

 Other _______________________________

Court Involved?  Yes  No Court Case # _______________________________________________

Referral Source Name and Phone ___________________________________________________________

What happened that you decided to come here now? ____________________________________________

_______________________________________________________________________________________

SOCIAL HISTORY

Are you:  Married  Divorced  Widowed  Separated

 Never Married

 In a committed relationship Name of spouse/significant other: _____________________________

Who is your support system including concerned persons, caring loved ones and family? ________________

________________________________________________________________________________________

If female, are you pregnant?  Yes

 No

Due Date? _______________________________________

Are you a veteran?  Yes  No

What are the primary sources of your income? __________________________________________________

Do you have legal problems?  Yes

 No

Probation/Parole?  Yes

 No

If yes, please explain ________________________________________________________________

__________________________________________________________________________________

Have you had a DUI?  Yes  No If yes, when and where? ____________________________________

Do you have charges pending or a scheduled court date?  Yes

 No

If yes, when? ___________________ Who is your attorney? _______________________________

ALCOHOL/DRUG USE HISTORY

Has anyone said they were concerned about your alcohol or drug use?  Yes  No

If yes, who? What was the reason for their concern? _______________________________________

__________________________________________________________________________________

G:\COMMON\forms\Screening – Eval.doc

Rev. 07/27/10 clp

Chemical Dependency - Assessment/screening Form

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