Chemical Dependency - Assessment/screening Form Page 5

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Name, Soc Sec #, Client ID, DOB
Initial Problem List (Transfer to Master Treatment Plan)
1.
_______________________________________________________________________________
2.
_______________________________________________________________________________
3.
_______________________________________________________________________________
Preliminary assessment: ___________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Recommendations: _______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Client’s Response to Recommendations:  Accepted  Refused  Other _________________________
Final disposition and/or action taken with referral sources: _________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Admitted to:  Detox Unit  Intensive Outpatient  Basic Education  Other (specify): ____________
Counselor Assigned to: _________________________________________ Professional #: ______________
Bed Assigned: ___________
Start date and time (for Outpatient): _____________________________
Payor Source:  Sliding Fee Scale
 START
 HHO  Passport
 Private Insurance
 Drug Court
 Full Fee
 Other __________________________________________
Counselor Signature______________________________________ Date _____________________________
G:\COMMON\forms\Screening – Eval.doc
Rev. 07/27/10 clp

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