Cord of Three Counseling Services Addiction Recovery Intake Form
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1 BACKGROUND INFORMATION Cord of Three Counseling Services Addiction Recovery Intake Form Client Home Phone Client Cell Phone Client Name: SSN: DOB: Address: City: State: GA Zip: Employer: Occupation: Home Phone: Emergency Contact Person: Emer. Contact #: Client Age: Client Gender: Client Ethnicity: Church of Attendance: Active Member: Yes No Referral Source/Contact: Presently living with: Marital Status: Highest Education Completed: Parents Single Elementary School Spouse Married High School Roommate Separated College Alone Divorced Graduate School Widowed Professional School Relationship history and children? (Time line) Employment History. Please write in black ink. Chief Complaint (What are the primary problems that have caused you to seek out counseling at this time?)
2 Have you ever received any previous counseling/psychiatric or substance abuse treatment? TX PROVIDER/ FACILITY NAME DATE REASON FOR TREATMENT LEVEL (check one) Inpatient, Partial, Residential, Out Pt MEDICAL HISTORY: (Please check any of the following medical problems you have experienced) Asthma Bowels Respiratory Encephalitis Herpes Cardiac Emphysema Ulcers Chlamydia Meningitis Diabetes Hypertension Cancer Gonorrhea Sickle Cell Anemia Cirrhosis Liver Glaucoma Syphilis Toxoplasmosis Thyroid Kidney Gynecological Arthritis Tuberculosis Rheumatic Fever Scarlet Fever Neurological exam Hemophilia Seizures, type: Chicken Pox Hepatitis, type: : MEDICATIONS: (All Current Medications You Are Taking) Current Medications Dosage/Frequency Prescribed by Last use Is medication being taken as prescribed? List all allergies (include medications, foods, insects, substances, & any others): Please list all health care providers treating you at this time: Physical Pain Screening: Please circle the face that corresponds to your level of physical pain today. If you have physical pain today, describe what is causing your pain: Have you talked with your medical doctor about your pain?
3 LEGAL STATUS ASSESSMENT: Please provide an explanation of any legal involvement: Are there any current/pending legal problems? Are you on probation/parole? (If yes, P.O. s name & phone) Do you have previous legal history? Additional legal information. (Timeline) Will legal situation impact treatment? Nutrition Screening: Please mark you height in inches and your weight in lbs. Please Circle each number if you answer yes to any of the questions below: I have lost or gained 10 lbs. in past 6 months 2 I do not have enough food to eat each day 1 I do not eat 1 or more days each month 2 I have an illness that has made me change the kind and/or 1 amount of food I eat I eat fewer than 2 meals per day 1 I eat few fruits or vegetables or milk products 1 I have 3 or more drinks of beer, liquor or wine each day 2 I have tooth or mouth problems that makes it hard to eat 1 I don t always have enough money to buy the food I need 1 I eat alone most of the time 1 I have a history of binging and/or purging 2 I exercise excessively to maintain weight 2 I am anorexic Good! 3 7 You are at moderate nutritional risk: See what can be done to improve your eating habits and lifestyle. 8 or more You are at high nutritional risk: You may need to be under the help of a qualified medical doctor or counselor. Yes ALCOHOL/DRUG HISTORY: Any History of drug/alcohol use? If, go to Psychosocial History. Alcohol Marijuana Stimulants Barbiturates Cocaine Hallucinogens (Acid/LSD) Methadone Pain Medications Crack Opiates Tranquilizers Over-the-counter Medications Tobacco Heroin Sedatives Crank Caffeine Inhalants Methamphetamine (Ecstasy, crystal meth) :
4 COMPLETE THE FOLLOWING FOR THE ITEMS CHECKED ABOVE: Substance Checked Amt/Frequency Duration of Use First Use Last Use Amt. used in last 24 hours Withdrawal Symptoms/behaviors from alcohol/drug use: (Check all that apply) Aggression/assaultive Cramps Agitation Weakness Profuse sweating Change in blood Tingling Rapid heart beat pressure Diarrhea Fever/chills Nausea/vomiting Tremors Irritability Delirium Anorexia None Anxiety Bipolar Depression Eating Disorder Trauma Schizophrenia Death by Suicide Substance Abuse Domestic Violence Behavioral Health History of Family Mother Father Sister Brother Aunt Uncle Children Grandparents Have you ever been a victim of physical/sexual abuse? Are you sexually active? Have you ever physically or sexually abused another person? PSYCHOSOCIAL HISTORY: Describe your leisure and recreational activities: What type of social activities do you participate in?
5 SUPPORT SYSTEMS (availability of family/friends to participate in treatment, special family concerns) LIST OF PEOPLE LIVING IN THE HOME, T INCLUDING YOURSELF: NAME RELATION TO CLIENT AGE GENDER OCCUPATION Do you want your significant other or anyone in your family to participate in your treatment? If so, who? REVIEW OF COMMUNITY RESOURCES (check all that apply now or that you have used in the past): Church Health Dept Medical Clinics Voc. Rehab Adult Ed. Housing Schools SSI/Medicaid SSA/Medicare Food Stamps/WIC Child Insurance Family/Friends Financial Aid DFCS: Name of current case worker community resources (please specify): Safety Risk Screening: Please Circle the number to the left if any of the following are true: Risk Factors 1 Current/past psychiatric diagnosis: I have been diagnosed with a mood disorder, psychotic disorder, alcohol/substance abuse addiction. 1 Key Symptoms: I experience any of the following symptoms: depression, impulsivity, hopelessness, anxiety/panic, insomnia, command hallucinations 2 Suicidal Behavior: I have a history of past attempts of suicide or self-injurious behaviors 1 Family: I have a family history of suicide or suicide attempts and/or a family history of mental health problems 1 Precipitating Factors: I have experienced public humiliation, shame or despair (i.e. loss of relationship, financial problems, health status changed) or I have been diagnosed with an ongoing medical illness 1 I have access to firearms Protective Factors -1 I have the ability to cope with stress and I have religious beliefs against self-harm -1 I have a responsibility to my children or loved ones and I have positive outlets for expressing myself and being understood Suicide Inquiry 2 I have a been thinking about suicide during the past 48 hours month Year 2 I know when, how and where I would commit suicide 2 I have attempted suicide in the past and I have rehearsed (literally or in my mind) how I would commit suicide or hurt myself 2 I have a desire to physically hurt someone else Risk Level Score: Complete Safety Plan if needed.
6 Please check any of the symptoms listed below which apply to you: Current History N/A Depressed mood Feelings of worthlessness Manic thought/behavior Crying spells Phobias Angry Anxious Obsessive/compulsive Changes in Appetite Change in Energy Level Sleep Disturbance Decreased Concentration Disorganized/Disoriented Social Withdrawal Binging/Purging Distractibility/Impulsivity Lying/Manipulative Property Destruction Stealing legal Issues Family Problems Religious/Spiritual Concerns Talk of Suicide Hallucinations What do you hope is changed as a result of coming to counseling? Strengths and Weaknesses. Any other information you would like for your counselor to know?
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