Chemical Dependency - Assessment/screening Form (Page 2 of 5) in pdf

Name, Soc Sec #, Client ID, DOB

At any time in your life, past or present, have you ever thought you might have a problem with alcohol or

drugs?  Yes  No If yes, explain: _________________________________________________

__________________________________________________________________________________

What is your drug of choice? ________________________________________________________________

FAMILY & CLIENT TREATMENT HISTORY

Have you ever had psychiatric treatment?  Yes

 No

 Past

 Present

If yes, what were you treated for? Where/when/by whom? _________________________________________

________________________________________________________________________________________

Have you ever taken medication(s) for psychiatric/emotional problems?  Yes  No  Past  Present

If yes, what/when? __________________________________________________________________

__________________________________________________________________________________

Is there any family history of alcohol/drug abuse or dependence?  Yes

 No If yes, explain: _________

________________________________________________________________________________________

Has anyone in your family ever been in treatment for alcohol or drug problems?  Yes

 No

If yes, who/why? ___________________________________________________________________

What is the longest period you have remained free of alcohol and drugs? _____________________________

How did you maintain your sobriety? __________________________________________________________

Have you ever attended AA or NA meetings?  Yes

 No

When? _____________________________

Did you find the meetings to be helpful?  Yes

 No

 N/A

Have you been in alcohol/drug treatment within the last two years?  Yes

 No

If Yes, for your most recent treatment, how long did you stay free from alcohol/drugs? _____________________

Did you attend AA or NA?  Yes

 No

If Yes, for how long and how many times/week? ___________________________________________________

STOP:

Counselor will complete the remainder of form

G:\COMMON\forms\Screening – Eval.doc

Rev. 07/27/10 clp

Chemical Dependency - Assessment/screening Form Page 2