INTAKE ASSESSMENT. 1. Print out the Intake Assessment or call ARISE Alcohol Recovery to have an assessment mailed to you.

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "INTAKE ASSESSMENT. 1. Print out the Intake Assessment or call ARISE Alcohol Recovery to have an assessment mailed to you."

Transcription

1 INTAKE ASSESSMENT Directions: Please complete all sections of the attached Intake Assessment form with as much accuracy as possible. You may have someone who knows you well assist you with completing the assessment; however, you are responsible for the accuracy of your answers. You may call ARISE if you have any questions about the admission process. In addition to completing this assessment, you will need to contact your physician(s) to have a copy of your medical and mental health records (if you have a psychiatrist) faxed to our office. These records must include your current laboratory reports, all current medications, all medical and mental health diagnoses and any medical or mental health treatments you are currently following. 1. Print out the Intake Assessment or call ARISE Alcohol Recovery to have an assessment mailed to you. 2. Complete the assessment (You may have someone assist you.) 3. Sign the Intake Assessment 4. Fax or mail your assessment to ARISE Alcohol Recovery 5. Have your physician(s) fax your medical and mental health records to us including: a) Current laboratory reports b) Current diagnosis (including medical and mental health) c) Current medications d) Current treatments 6. Call or ARISE to tell us you have sent us your assessment so that we can contact you in the event we do not receive it. ARISE ALCOHOL RECOVERY P.O. Box 886 Horse Shoe, NC : (828) Fax Number: (828) Web:

2 INTAKE ASSESSMENT Date: How did you hear about ARISE? Name: First Middle Initial Last Age Date of Birth Sex Highest level of education Marital Status: Single Married Divorced Widow/Widower Separated Never Married Do you live alone? If not, who do you live with? Who will be your support person throughout the six week program? (This person will stay with you during your initial detoxification period and attend the weekly family sessions for the entire six week program.) Name Relationship Telephone Name Relationship Telephone Name of employer (We will not contact you at your place of business nor will we contact your employer without your permission.) Current Legal Status including pending charges, parole status, probation, etc. Military History: Branch Date Type of Discharge Residence: House Condo Apartment Retirement Community Own Rent Primary Physician Psychiatrist ALCOHOL HISTORY Why are you seeking a program for alcohol recovery at this time?

3 What is it about this program that especially attracts you? PAGE 2 How old were you when you had your first drink? When did you start drinking regularly? How old were you when your drinking became a problem? What form of alcohol do you drink? How much and how often do you drink? Are you continuing to drink at this time? Please check all symptoms you have experienced while drinking or detoxing from alcohol. Black outs Seizures DT s Delusions Hallucinations Tremors Sweating Nausea Vomiting Cramping Agitation Insomnia OTHER SUBSTANCE HISTORY Are you currently taking any Benzodiazepines (Ativan, Valium, Xanax, Klonipin)? If so, please list names, amounts and times you take these. Are you currently taking any Opiates (Lorcet, Dilaudid, Morphine, OxyContin, Lortab, Hydrocodone, Methadone, Heroin, Demerol, Darvocet)? If so, please list names, amounts, by mouth or injection and times you take these?

4 Are you currently using Cocaine or Crack? If so, please list amounts, method and times you take these. PAGE 3 Are you currently taking any Amphetamines (Crystal meth, diet pills, special K, scoop, GHB, ICE, XTC, crank, Adderall, Ritalin, dextroamphetamine, speed)? If so, please list names, amounts and times you use these. Are you currently taking any Sedatives (SOMA, Ambien, barbiturates, other)? If so, please list names, amounts and times you take these. Are you currently taking any Hallucinogens (LSD, PCP, mushrooms, other)? If so, please list names, amounts and times you take these. Are you currently using Marijuana? If so, please list amounts and times you take this. Do you smoke or chew tobacco? If so, how much and how often? MENTAL HEALTH HISTORY Previous Psychiatric/Chemical Dependency Treatment Programs Date Location Inpatient Outpatient Do you currently have thoughts of suicide? Is so, please describe. Have you ever attempted suicide in the past? If so, what method did you attempt? Has anyone in your family ever committed suicide? If so, who? By what method?

5 Have you experienced any recent losses (death, move, relationship, health, etc.) Please describe. PAGE 4 Do you ever have violent thoughts toward people or property? Do you have a history of personal trauma or abuse, either emotional or physical? Yes Have you ever been diagnosed with Post Traumatic Stress Disorder? Yes Is your remote memory intact? Is your recent memory intact? MEDICAL HISTORY What is your height? What is your current weight? To what medications and foods are you allergic? What type of reactions do you have to each? List all your current medications, amount taken and how often. What is the name and telephone number of the pharmacy(s) where you purchase your medications? List all medical problems you are currently experiencing.

6 List other medical treatment and all surgeries. Date Location Inpatient Outpatient PAGE 5 Do you have an eating disorder (anorexia, bulimia, binge, purge)? Yes If yes, please explain. Have you ever been diagnosed with HIV/AIDS? Yes PARTICIPATATION IN THE ARISE PROGRAM Are you physically able to walk, bend and stretch? Yes If, please explain. Do you have any physical limitations that would prevent you from taking part in physical activities? If so, please explain. Do you currently have any gastro intestinal problems that would prevent you from taking food supplements and eating a typically healthy diet? If so, please explain. Do you have difficulty swallowing capsules? Yes Are you willing to follow a regular schedule for taking food supplements? Yes Can you be committed to following a healthy nutritional plan and sticking to it? Yes What concerns might you have about being able to follow the nutritional guidelines? HOLISTIC ORIENTATION

7 PAGE 6 Please number the words below in the order of how you would best describe your outlook on life. Conservative Traditional Open minded Flexible Holistic n Traditional Please check all the words below that you are comfortable with. Spirit God Source Universal Mind Universal Consciousness Other: ne of the above Have you ever attended AA? Yes If yes, how often did you attend? Regularly Sometimes Rarely Never What requests, questions or concerns do you have about the ARISE program? By signing this Intake Assessment I am agreeing to allow ARISE Alcohol Recovery L.L.C. to contact my pharmacy and/or physician(s) for verification of or additional information in order to process my request for admission into the ARISE Alcohol Recovery program. This information will be kept confidential and shared with no other persons for any reason. It may be necessary to contact my Support Person for additional information. By signing this Intake Assessment I agree to allow ARISE Alcohol Recovery L.L.C. to contact my Support Person. Support Person s Name My Signature Date Thank you for taking the time to complete this intake assessment. Our goal is to serve you in the best possible way. We look forward to receiving your medical records from your physician(s) so that we can make an informed decision regarding the appropriateness of our program for your needs and best interest. As soon as we receive those records we will contact you.

Revised April 1, 2015 Page 1 of 5

Revised April 1, 2015 Page 1 of 5 Interview Date: Community Treatment Center 1215 Lake Drive Cocoa, Florida 32922 Phone: 321-632-5958 Fax: 321-632-2533 Do you have a substance abuse problem? Yes No Do you have a mental health diagnosis?

More information

COLLEGIATE RECOVERY COMMUNITY Application for the OSU CRC and Recovery House

COLLEGIATE RECOVERY COMMUNITY Application for the OSU CRC and Recovery House REQUIREMENTS FOR ADMISSION TO THE CRC Must be admitted to The Ohio State University Must follow OSU Code of Student Conduct Preferred minimum of 6 months complete abstinence from all drugs and alcohol,

More information

Levels of Care Guide

Levels of Care Guide Levels of Care Guide What Type of Drug Rehab Is Right for You? A Guide to Understanding Levels of Care in Addiction Treatment Looking for help for yourself or a loved one? Congratulations! You are on the

More information

General Information. Age: Date of Birth: Gender (circle one) Male Female. Address: City: State: Zip Code: Telephone Numbers: (day) (evening)

General Information. Age: Date of Birth: Gender (circle one) Male Female. Address: City: State: Zip Code: Telephone Numbers: (day) (evening) Kelly Bernstein, MS, LCDC, LPC Medical Center Psychological Services 7272 Wurzbach Road, Suite 1504 San Antonio, Texas 78240 Office: (210) 522-1187 Fax: (210) 647-7805 Functional Assessment Tool The purpose

More information

Grant House APPLICATION

Grant House APPLICATION Street Haven Addiction Services Grant House APPLICATION Dear applicant, We are pleased you are considering Grant House for treatment and hope in this package to provide more information about our program.

More information

Comprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms,

Comprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms, Comprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms, PATIENT INFORMATION Last Name/ First Name/ M.I. Social Security Number: Date of Birth (MM/DD/YY):

More information

Please fill out the application and fax or mail back to us. Our receipt of your application does not guarantee a bed date or acceptance.

Please fill out the application and fax or mail back to us. Our receipt of your application does not guarantee a bed date or acceptance. Dear Applicant: Attached is the application you requested for Paducah Lifeline Ministries or Ladies Living Free. We are delighted you have chosen our facility and look forward to assisting you on your

More information

ALPHA RECOVERY CENTERS Application & Screening Data

ALPHA RECOVERY CENTERS Application & Screening Data ALPHA RECOVERY CENTERS Application & Screening Data I am applying for admission to: Alpha Recovery Centers Atlanta Alpha Recovery Centers - Brunswick Thank you for your interest in Alpha Recovery Centers.

More information

PATIENT TREATMENT AGREEMENT

PATIENT TREATMENT AGREEMENT PATIENT TREATMENT AGREEMENT Patient Name: : As a participant in buprenorphine treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment agreement as follows: I

More information

APPLICATION TO RESIDENTIAL TREATMENT

APPLICATION TO RESIDENTIAL TREATMENT APPLICATION TO RESIDENTIAL TREATMENT Select your preference for referral to one of the following Treatment Centres: Beaver Lake Wah-Pow Treatment Centre Beaver Lake (780) 623-2553 (Tel) (780) 623-4076

More information

SASKATCHEWAN NNADAP TREATMENT SERVICES APPLICATION FORM Revised June, 2009 VAN LOONVCONSULTING

SASKATCHEWAN NNADAP TREATMENT SERVICES APPLICATION FORM Revised June, 2009 VAN LOONVCONSULTING SASKATCHEWAN NNADAP TREATMENT SERVICES APPLICATION FORM Revised June, 2009 VAN LOONVCONSULTING This application is the first step required to pre-screen applicants for adult treatment at any of the NNADAP

More information

Mino Ayaa Ta Win Helping Ourselves Heal

Mino Ayaa Ta Win Helping Ourselves Heal Fort Frances Tribal Health Area Health Services Inc. Behaviour Health Services P.O. Box 608, Fort Frances, Ontario, P9A3M9 Mino Ayaa Ta Win Helping Ourselves Heal Intake Form & Referral Package Pre-Treatment

More information

And, despite the numbers, for many people, the Facts About Drugs are not clear.

And, despite the numbers, for many people, the Facts About Drugs are not clear. According to the National Survey on Drug Use and Health (NSDUH), an estimated 20 million Americans aged 12 or older used an illegal drug in the past 30 days. This estimate represents 8% percent of the

More information

Intake Form for Testing Services. Last Name First Name Date of Birth. Address City State/ZIP Sex (M/F)

Intake Form for Testing Services. Last Name First Name Date of Birth. Address City State/ZIP Sex (M/F) Intake Form for Testing Services Date Last Name First Name Date of Birth Address City State/ZIP Sex (M/F) Email Address: @ CAN I EMAIL YOU FOR: (CIRCLE ALL THAT APPLY) SCHEDULING SERVICES UPDATES AVAILABLE

More information

SUBSTANCE USE QUESTIONNAIRE. Name: Date: Ever Used? Ever a Problem? Age of 1 st Use When last used?

SUBSTANCE USE QUESTIONNAIRE. Name: Date: Ever Used? Ever a Problem? Age of 1 st Use When last used? SUBSTANCE USE QUESTIONNAIRE Name: Date: Part I. Substance Abuse History Ever Used? Ever a Problem? Age of 1 st Use When last used? Alcohol Yes No Yes No Barbiturates or Yes No Yes No other sleeping pills

More information

Feeling that you have to use the drug regularly this can be daily or even several times a day. Failing in your attempts to stop using the drug

Feeling that you have to use the drug regularly this can be daily or even several times a day. Failing in your attempts to stop using the drug Drug addiction Definition Drug addiction is a dependence on an illegal drug or a medication. When you're addicted, you may not be able to control your drug use and you may continue using the drug despite

More information

Substance Use Disorder Overview. Presented By Ecole J. Barrow-Brooks M.Ed & Darlene D. Owens MBA, LBSW, CADC, ADS

Substance Use Disorder Overview. Presented By Ecole J. Barrow-Brooks M.Ed & Darlene D. Owens MBA, LBSW, CADC, ADS Substance Use Disorder Overview Presented By Ecole J. Barrow-Brooks M.Ed & Darlene D. Owens MBA, LBSW, CADC, ADS 1 National Issue There continues to be a large treatment gap in the U.S. In 2013, an estimated

More information

Downers/Depressants (pages 40-50)

Downers/Depressants (pages 40-50) Downers/Depressants (pages 40-50) Read pages 49-54, 59-60, and 78-79 of the booklet, Street Drugs. Pages 40-50 of the text. Narcotics: Prescription Origin: Southeast Asia, Southwest Asia, and in the Western

More information

THREE VOICES OF HEALING SOCIETY

THREE VOICES OF HEALING SOCIETY THREE VOICES OF HEALING SOCIETY 1001 Capilo Way Invermere, BC Mailing Address Box 325 Invermere, BC V0A 1K0 Telephone: 778-526-2501 Facsimile: 778-526-2505 Toll Free 855-526-2502 Electronic mail: admin@healingisajourney.com

More information

New Port Centre. 5. DHQ Drug History Questionnaire 6. Adverse Consequences Questionnaire 7. Tracking Sheet With Scores of Other Provincial Assessments

New Port Centre. 5. DHQ Drug History Questionnaire 6. Adverse Consequences Questionnaire 7. Tracking Sheet With Scores of Other Provincial Assessments New Port Centre Page 1 of 2 NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne ON, L3K 2N7 Phone (905) 378-4647 Ext 32500 Fax: (905) 834-3002 E-mail: NewPortAdmin@niagarahealth.on.ca

More information

Cord of Three Counseling Services Addiction Recovery Intake Form

Cord of Three Counseling Services Addiction Recovery Intake Form 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: Email: Occupation:

More information

About drugs. Psychoactive drugs. Drugs are substances that change a person s physical or mental state.

About drugs. Psychoactive drugs. Drugs are substances that change a person s physical or mental state. 1 About drugs Drugs are substances that change a person s physical or mental state. The vast majority of drugs are used to treat medical conditions, both physical and mental. Some, however, are used outside

More information

Santa Fe Sage Counseling Center

Santa Fe Sage Counseling Center Couple/Family Client Intake Date: Names: Partner/Parent/Child (circle one) Partner/Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Insurance ID #:

More information

Narrative Report - BHI-MV Behavioral Health Index - Multimedia Version

Narrative Report - BHI-MV Behavioral Health Index - Multimedia Version Site: Address: Behavioral Health Services 320 Needham St., Newton, MA Narrative Report - BHI-MV Behavioral Health Index - Multimedia Version Summary of Results for: Client Name: Sample Client Client ID:

More information

CO-OCCURRING DISORDERS. Michaelene Spence MA LADC 8/8/12

CO-OCCURRING DISORDERS. Michaelene Spence MA LADC 8/8/12 CO-OCCURRING DISORDERS Michaelene Spence MA LADC 8/8/12 Activity Chemical Health? Mental Health? Video- What is Addiction HBO Terminology MI/CD: Mental Illness/Chemical Dependency IDDT: Integrated Dual

More information

Substance Abuse Prevention and Treatment Agency March, 2012

Substance Abuse Prevention and Treatment Agency March, 2012 Substance Abuse Prevention and Treatment Agency March, 2012 1 The mission of the Substance Abuse Prevention and Treatment Agency (SAPTA) is to reduce the impact of substance abuse in Nevada. SAPTA funds

More information

North Bay Regional Health Centre

North Bay Regional Health Centre Addictions and Mental Health Division Programs Central Intake Referral Form The Central Intake Referral Form is used in the District of Nipissing by the North Bay Regional Health Centre s Addictions and

More information

Easy Does It, Inc. Transitional Housing Application

Easy Does It, Inc. Transitional Housing Application Easy Does It Inc. of Reading and Leesport Housing Programs Easy Does It, Inc. Transitional Housing Application Welcome Thank you for applying to Easy Does It, Inc. ( EDI ) a non-profit charitable organization

More information

Santa Fe Recovery Center Follow Up Survey Form

Santa Fe Recovery Center Follow Up Survey Form Santa Fe Recovery Center Follow Up Survey Form Clients Name Participant ID / Chart Number Discharge Date / / Date Telephone Survey was Completed / / Month Day Year Survey Type (Check one) 3 month follow

More information

Michael Brennan, MA, LMHC Providence St. Peter Hospital Crisis Services

Michael Brennan, MA, LMHC Providence St. Peter Hospital Crisis Services Michael Brennan, MA, LMHC Providence St. Peter Hospital Crisis Services Welcome to the E.R.: Emergency: noun Webster 1. a sudden, urgent, usually unexpected occurrence or occasion requiring immediate action.

More information

APPLICATION FOR Page 1/7 RESIDENTIAL TREATMENT

APPLICATION FOR Page 1/7 RESIDENTIAL TREATMENT APPLICATION FOR Page 1/7 Instructions: The following form is required to begin the application process to Stonehenge. The form should be printed and completed by hand, then faxed or mailed to Stonehenge

More information

CORE ADDICTION ASSESSMENT / ADMISSION PACKAGE. Date of Birth: Day Month Year

CORE ADDICTION ASSESSMENT / ADMISSION PACKAGE. Date of Birth: Day Month Year Windsor Addiction Assessment & Outpatient Service Tayfour Campus, Withdrawal Management & Assessment Centre 1453 Prince Road, Windsor, Ontario N9C 3Z4 Phone: 519-257-5220 Fax: 519-257-5235 CORE ADDICTION

More information

Residential Sub-Acute Detoxification Guidelines

Residential Sub-Acute Detoxification Guidelines I. Background Information A. Definition of Detoxification Residential Sub-Acute Detoxification Guidelines SAMSA s TIP #45, Detoxification and Substance Abuse Treatment: Treatment Improvement Protocols

More information

Methamphetamine. Like heroin, meth is a drug that is illegal in some areas of the world. Meth is a highly addictive drug.

Methamphetamine. Like heroin, meth is a drug that is illegal in some areas of the world. Meth is a highly addictive drug. Methamphetamine Introduction Methamphetamine is a very addictive stimulant drug. People who use it can form a strong addiction. Addiction is when a drug user can t stop taking a drug, even when he or she

More information

CIGI Direct Insurance Services, Inc. QUICK QUOTE CORONARY ANGIOPLASTY/CORONARY BYPASS

CIGI Direct Insurance Services, Inc. QUICK QUOTE CORONARY ANGIOPLASTY/CORONARY BYPASS QUICK QUOTE CORONARY ANGIOPLASTY/CORONARY BYPASS Amount of Insurance $ Type of Insurance 1. Has patient had: Date of last symptom, list date (or dates if more than one ) Angina pectoris (heart pain)? r

More information

Neuropsychological Testing Appointment

Neuropsychological Testing Appointment Neuropsychological Testing Appointment Steven A. Rogers, PhD Kathleen D. Tingus, PhD 1701 Solar Drive, Suite 140 Oxnard, CA 93030 When will it be? Date: Time: Examiner: What will I have to do? Each appointment

More information

TEEN CHALLENGE CENTER--PENSACOLA, FLORIDA STUDENT APPLICATION FOR PROGRAM ENTRY. Personal Data and Information. In Case of Emergency Please Contact

TEEN CHALLENGE CENTER--PENSACOLA, FLORIDA STUDENT APPLICATION FOR PROGRAM ENTRY. Personal Data and Information. In Case of Emergency Please Contact TEEN CHALLENGE CENTER--PENSACOLA, FLORIDA STUDENT APPLICATION FOR PROGRAM ENTRY Personal Data and Information TODAY'S DATE BIRTH DATE SOCIAL SECURITY NUMBER LAST NAME FIRST NAME MIDDLE NAME STREET ADDRESS

More information

WYOMING PROFESSIONAL ASSISTANCE PROGRAM APPLICATION FOR PARTICIPATION NAME: SOC. SEC. # HOME ADDRESS: PHONE # CITY: STATE: ZIP:

WYOMING PROFESSIONAL ASSISTANCE PROGRAM APPLICATION FOR PARTICIPATION NAME: SOC. SEC. # HOME ADDRESS: PHONE # CITY: STATE: ZIP: WYOMING PROFESSIONAL ASSISTANCE PROGRAM APPLICATION FOR PARTICIPATION NAME: SOC. SEC. # HOME ADDRESS: PHONE # CITY: STATE: ZIP: BIRTHDATE: AGE: SEX: ( M ) ( F ) RACE: MARITAL STATUS: Married ( ) Separated

More information

34 th Judicial District Substance Abuse Study Guide

34 th Judicial District Substance Abuse Study Guide 34 th Judicial District Substance Abuse Study Guide What is Drug Addiction? 2 It is characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that

More information

INFORMATION BRIEF. Overview. Prescription Drug Abuse Among Young People

INFORMATION BRIEF. Overview. Prescription Drug Abuse Among Young People Product No. 2002-L0424-004 INFORMATION BRIEF AUGUST 2002 U. S. D E P A R T M E N T O F J U S T I C E NDIC and Stockbyte Overview Prescription drugs, a category of psychotherapeutics that comprises prescription-type

More information

Addiction Severity Index Fifth Edition

Addiction Severity Index Fifth Edition INSTRUCTIONS 1. Leave No Blanks - Where appropriate code items: X = question not answered N = questions not applicable Use only one character per item. 2. Item numbers underlined are to be asked at follow-up.

More information

MAT Disclosures & Consents 1 of 6. Authorization & Disclosure

MAT Disclosures & Consents 1 of 6. Authorization & Disclosure MAT Disclosures & Consents 1 of 6 Authorization & Disclosure ***YOUR INSURANCE MAY NOT PAY FOR ROUTINE SCREENING*** *** APPROPRIATE SCREENING DIAGNOSES MUST BE PROVIDED WHEN INDICATED*** Urine Drug Test

More information

Drug and Alcohol Abuse Training revised: October 2015

Drug and Alcohol Abuse Training revised: October 2015 Drug and Alcohol Abuse Training revised: October 2015 FMCSA is considering going to a seven panel and possibly ten panel. Hair testing may also be acceptable. What is a Drug? A substance which

More information

City of San Antonio Police Department

City of San Antonio Police Department City of San Antonio Police Department Applicant Processing Detail APPLICATION FOR THE POSITION OF: POLICE CADET - 0602 NAME OF APPLICANT: DATE COMPLETED: Last Name (Suffix Sr, Jr, III, etc), First Name,

More information

NEW PATIENT INFORMATION

NEW PATIENT INFORMATION NEW PATIENT INFORMATION Date Patient Name Sex Age DOB / / Address City State Zip Phone Email Emergency Contact: Relationship to patient: Phone #(s) How did you hear about my practice? RESPONSIBLE PARTY

More information

Young Adult Prescription Drug Use and Co-Occurring Mental Health Disorders Presenter: Jonathan Beazley, LADC LMFT Moderator: Cindy Rodgers

Young Adult Prescription Drug Use and Co-Occurring Mental Health Disorders Presenter: Jonathan Beazley, LADC LMFT Moderator: Cindy Rodgers Young Adult Prescription Drug Use and Co-Occurring Mental Health Disorders Presenter: Jonathan Beazley, LADC LMFT Moderator: Cindy Rodgers Audio will begin at 2:00 PM ET. You can listen through your computer

More information

Rekindling House Dual Diagnosis Specialist

Rekindling House Dual Diagnosis Specialist Rekindling House Dual Diagnosis Specialist Tel: 01582 456 556 APPLICATION FOR TREATMENT Application Form / Comprehensive Assessment Form Please provide as much detail as you can it will help us process

More information

Treatment Program Referral Package. The Salvation Army s Intensive Eight Week Non-Residential Treatment Program

Treatment Program Referral Package. The Salvation Army s Intensive Eight Week Non-Residential Treatment Program Treatment Program Referral Package The Salvation Army s Intensive Eight Week Non-Residential Treatment Program The Salvation Army Williams Lake Corp 267 Borland Street Williams Lake, B.C. V2G 1R4 250-305-2492

More information

National Survey of Pain Killer Dependence and Treatment. Conducted by Schulman, Ronca and Bucuvalas, Inc.

National Survey of Pain Killer Dependence and Treatment. Conducted by Schulman, Ronca and Bucuvalas, Inc. National Survey of Pain Killer Dependence and Treatment Conducted by Schulman, Ronca and Bucuvalas, Inc. Quality of Life In America Not Sure 3% Better 24% Worse 42% About the Same 31% Q1. Compared to ten

More information

What Is Medically. Supervised Detoxification? Chapter 13

What Is Medically. Supervised Detoxification? Chapter 13 Chapter 13 What Is Medically Supervised Detoxification? T I have been a heroin addict for three years and am desperately trying to stop. As the withdrawal symptoms are very severe, the muscle cramps, shakes,

More information

YORK COUNTY COURT OF COMMON PLEAS

YORK COUNTY COURT OF COMMON PLEAS YORK COUNTY COURT OF COMMON PLEAS VETERANS TREATMENT COURT Participant MANUAL WHAT DO YOU NEED TO KNOW ABOUT VETERANS COURT? Established FEBRUARY 2012 Manual Created: November 2011 Veterans Court lasts

More information

Like cocaine, heroin is a drug that is illegal in some areas of the world. Heroin is highly addictive.

Like cocaine, heroin is a drug that is illegal in some areas of the world. Heroin is highly addictive. Heroin Introduction Heroin is a powerful drug that affects the brain. People who use it can form a strong addiction. Addiction is when a drug user can t stop taking a drug, even when he or she wants to.

More information

Substance Abuse Treatment Admissions for Abuse of Benzodiazepines

Substance Abuse Treatment Admissions for Abuse of Benzodiazepines Treatment Episode Data Set The TEDS Report June 2, 2011 Substance Abuse Treatment Admissions for Abuse of Benzodiazepines Benzodiazepines are a class of central nervous system depressant drugs that are

More information

SUBSTANCE ABUSE ASSESSMENT FORM

SUBSTANCE ABUSE ASSESSMENT FORM SUBSTANCE ABUSE ASSESSMENT FORM Please make copies as needed and please type or print legibly. Instructions for use: Complete this form and use these questions to guide the EAP client interview when conducting

More information

Sample Patient Agreement Forms

Sample Patient Agreement Forms Sample Patient Agreement Forms Introduction This resource includes two sample patient agreement forms that can be used with patients who are beginning long-term treatment with opioid analgesics or other

More information

Opioid overdose can occur when a patient misunderstands the directions

Opioid overdose can occur when a patient misunderstands the directions Facts About Opioid Overdose How Does an Overdose Occur? Opioid overdose can occur when a patient misunderstands the directions for use, accidentally takes an extra dose, or deliberately misuses a prescription

More information

Psychiatric Consultants of Atlanta, P.C. 1835 Savoy Drive Suite 101 Atlanta, Georgia 30341 Phone: 770-234-0981 Fax: 770-234-0252 www.pcatl.

Psychiatric Consultants of Atlanta, P.C. 1835 Savoy Drive Suite 101 Atlanta, Georgia 30341 Phone: 770-234-0981 Fax: 770-234-0252 www.pcatl. Psychiatric Consultants of Atlanta, P.C. 1835 Savoy Drive Suite 101 Atlanta, Georgia 30341 Phone: 770-234-0981 Fax: 770-234-0252 www.pcatl.com CONTACT INFORMATION AND PERSONAL DATA Name: Date of Birth:

More information

ALCOHOL AND DRUG USE ASSESSMENT

ALCOHOL AND DRUG USE ASSESSMENT ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) Source: The items are from the ASSIST Scale. Public Domain Reference: WHO ASSIST Working Group (2002). The Alcohol, Smoking and Substance

More information

Patient Information and Consent to Treatment with Buprenorphine

Patient Information and Consent to Treatment with Buprenorphine 1063 Lower Main St, Ste C212 JEFFREY H. CHESTER, DO Phone 808.249.8887-6006 www.ponohealthcare.com Board Certified by American Board of Physical Medicine & Rehabilitation Board Certified by American Society

More information

THREE VOICES OF HEALING SOCIETY

THREE VOICES OF HEALING SOCIETY THREE VOICES OF HEALING SOCIETY 1001 Capilo Way Invermere, BC Mailing Address Box 325 Invermere, BC V0A 1K0 Telephone: 778-526-2501 Facsimile: 778-526-2505 Electronic mail: admin@healingisajourney.com

More information

Testimony Engrossed House Bill 1101 Department of Human Services Senate Human Services Committee Senator Judy Lee, Chairman February 19, 2013

Testimony Engrossed House Bill 1101 Department of Human Services Senate Human Services Committee Senator Judy Lee, Chairman February 19, 2013 Testimony Engrossed House Bill 1101 Department of Human Services Senate Human Services Committee Senator Judy Lee, Chairman February 19, 2013 Chairman Lee, members of the Senate Human Services Committee,

More information

THE SHEPHERD S INN Attention Intake Coordinator 156 Mills St, Atlanta, Georgia 30313 Phone: (404) 588-4015 Fax: (404) 215-9470 www.atlantamission.

THE SHEPHERD S INN Attention Intake Coordinator 156 Mills St, Atlanta, Georgia 30313 Phone: (404) 588-4015 Fax: (404) 215-9470 www.atlantamission. THE SHEPHERD S INN Attention Intake Coordinator 156 Mills St, Atlanta, Georgia 30313 Phone: (404) 588-4015 Fax: (404) 215-9470 www.atlantamission.org PDP INTAKE APPLICATION Thank you for taking this important

More information

INFORMATION YOU NEED FOR INJURY PREVENTION APPOINTMENT

INFORMATION YOU NEED FOR INJURY PREVENTION APPOINTMENT INFORMATION YOU NEED FOR INJURY PREVENTION APPOINTMENT Injury Prevention and Pointe Assessment appointments are held at Thirroul Physiotherapy & Sports Injury Clinic which is located at Suite 14, 345 Lawrence

More information

Template for Assessing a Client s Substance Use Developed by Cynthia Glidden-Tracey, Ph.D.

Template for Assessing a Client s Substance Use Developed by Cynthia Glidden-Tracey, Ph.D. Template for Assessing a Client s Substance Use Developed by Cynthia Glidden-Tracey, Ph.D. Client s Name Date and circumstances of Assessment a. Client s Reason for Seeking Assessment b. Substance Use

More information

What you need for Your to know Safety about longterm. opioid pain care. What you need to know about long-term opioid

What you need for Your to know Safety about longterm. opioid pain care. What you need to know about long-term opioid What you need to know about longterm opioid pain care. What you need to know about long-term opioid and the Safety of Others pain care. TAKING What you OPIOIDS need to know about long-term RESPONSIBLY

More information

Prescription for Danger

Prescription for Danger Prescription for Danger A Report on the Troubling Trend of Prescription and Over-the-Counter Drug Abuse Among the Nation s Teens OFFICE OF NATIONAL DRUG CONTROL POLICY EXECUTIVE OFFICE OF THE PRESIDENT

More information

Routes of Use. Overdose and EMS. Injection. Ingestion. Inhalation. Absorption 1/2/2013. Injection Ingestion Inhalation Absorption.

Routes of Use. Overdose and EMS. Injection. Ingestion. Inhalation. Absorption 1/2/2013. Injection Ingestion Inhalation Absorption. Routes of Use Overdose and EMS Injection Ingestion Inhalation Absorption Shaun Pitts, AEMT Venomous bites Common drugs Heroin Cocaine Meth Injection Ingestion Cleaning solutions Household plants Medications

More information

CHAPTER 3: Patient Admissions to Treatment for Abuse of Alcohol and Drugs in Appalachia, 2000 2004

CHAPTER 3: Patient Admissions to Treatment for Abuse of Alcohol and Drugs in Appalachia, 2000 2004 CHAPTER 3: Patient Admissions to Treatment for Abuse of Alcohol and Drugs in Appalachia, 2000 2004 3.1 Introduction Thousands of public and private treatment facilities are available across the United

More information

FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA

FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING

More information

Down the Up Staircase

Down the Up Staircase Down the Up Staircase Addiction is only a few steps away Supplemental Information on Oxycontin/Heroin Abuse Past & present youth trends? Then Cigarettes Alcohol Marijuana + Now OxyContin Heroin Why do

More information

X. Capsules; pills; Stimulants; increased energy powder; rock alertness; extreme anxiety; temporary mental illness

X. Capsules; pills; Stimulants; increased energy powder; rock alertness; extreme anxiety; temporary mental illness Cadet Name: Date: 1. (U4C3L1:Q1) Study the table and indicate the type of drugs that are described in rows X, Y and Z. Drug Forms of the Drug Uses and Effects X. Capsules; pills; Stimulants; increased

More information

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:

More information

Staff receiving this information. Last name First name Middle name. - - Date of birth Current age Social security number

Staff receiving this information. Last name First name Middle name. - - Date of birth Current age Social security number PE IEL Drug/Alcohol Residential Treatment Center P.O. Box 250 Johnstown, Pennsylvania 15907 (Phone) 814-536-2111 (Fax) 814-539-2871 Telephone and Interview Application for Treatment Admission Today s date

More information

Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #:

Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Intake Form PATIENT INFORMATION Patient Last Name: First Name: Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Gender: Employer:

More information

ALBERTA REGION YSAC YOUTH RESIDENTIAL TREATMENT ADMISSION FORM

ALBERTA REGION YSAC YOUTH RESIDENTIAL TREATMENT ADMISSION FORM ALBERTA REGION YSAC YOUTH RESIDENTIAL TREATMENT ADMISSION FORM Select your preference to one of the following Treatment Centres: Siksika Medicine Lodge Kainai Adolescent Treatment Center Siksika Nation,

More information

WITH OVER 20 YEARS OF EXPERIENCE, Unity Chemical Dependency is the Rochester area s most experienced and comprehensive treatment provider.

WITH OVER 20 YEARS OF EXPERIENCE, Unity Chemical Dependency is the Rochester area s most experienced and comprehensive treatment provider. WITH OVER 20 YEARS OF EXPERIENCE, Unity Chemical Dependency is the Rochester area s most experienced and comprehensive treatment provider. Our highly trained and dedicated team of counselors and physicians

More information

Date of Current Marriage/Separation: Highest Level of Education:

Date of Current Marriage/Separation: Highest Level of Education: ADULT INTAKE FORM Name: Date: Social Security: Home Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: May we call you and leave messages at home? Yes No May we call you and leave messages

More information

Drug and Alcohol Addiction Terms and Definitions A

Drug and Alcohol Addiction Terms and Definitions A Disclaimer The material listed below is for information only and is not advice. Listing of any resource does not imply endorsement and readers need to assess whether any information found is suitable for

More information

CBT/OTEP 937 Street Medicine Street Drugs

CBT/OTEP 937 Street Medicine Street Drugs Seattle-King County EMS Seattle-King County Emergency Medical Services Division Public Health - Seattle/King County 401 5th Avenue, Suite 1200 Seattle, WA 98104 February 2009 CBT/OTEP 937 Street Medicine

More information

DRUG USE. 1300 136 588 ndss.com.au AND TYPE 1 DIABETES

DRUG USE. 1300 136 588 ndss.com.au AND TYPE 1 DIABETES DRUG USE AND TYPE 1 DIABETES 1300 136 588 ndss.com.au The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered by Diabetes Australia. Contents Topic Page

More information

INTAKE APPLICATION. MSH PDP Intake Application 090210 AUM Page 1 of 5

INTAKE APPLICATION. MSH PDP Intake Application 090210 AUM Page 1 of 5 MY SISTER S HOUSE Attention Intake Coordinator 921 Howell Mill Road NW, Atlanta, GA 30318 Phone: (404) 367-2476; Fax: (404) 875-6675.atlantamission.org INTAKE APPLICATION Thank you for taking this important

More information

Your Company 123 Company Ave. Philadelphia PA 00000 (215) 000-0000 COMPARISON REPORT. John B Smith

Your Company 123 Company Ave. Philadelphia PA 00000 (215) 000-0000 COMPARISON REPORT. John B Smith Your Company 123 Company Ave Philadelphia PA 00000 (215) 000-0000 COMPARISON REPORT FICTITIOUS CLIENT The following is a report of 's baseline Addiction Severity Index information collected on compared

More information

Crosswalk Management System

Crosswalk Management System Crosswalk Management System Report Filename Run by REPORT CROSSWALK TO STATE adobe pdf OPS$PCUMMING Report Date 04-MAR-13 01:34 OPS$PCUMMING Page 2 of 32 Status : FN Media ID : CalOMS - CA Start Date :

More information

PENNINGTON COUNTY SHERIFF S OFFICE CITY/COUNTY ALCOHOL & DRUG PROGRAMS

PENNINGTON COUNTY SHERIFF S OFFICE CITY/COUNTY ALCOHOL & DRUG PROGRAMS PENNINGTON COUNTY SHERIFF S OFFICE CITY/COUNTY ALCOHOL & DRUG PROGRAMS POLICY NO: CC ORDER NO: REVISED: 04-07-2015 REFERENCES: CHAPTER: Medical Medication Control EFFECTIVE: 12-09-2010 APPROVED BY: Sheriff

More information

SCID-I (for DSM-IV-TR) Alcohol Abuse (JAN 2010) Substance Use Disorders E. 2

SCID-I (for DSM-IV-TR) Alcohol Abuse (JAN 2010) Substance Use Disorders E. 2 SCID-I (for DSM-IV-TR) Alcohol Abuse (JAN 2010) Substance Use Disorders E. 2 *LIFETIME ALCOHOL ABUSE* IF DEFINITE PERIOD: Let me ask you a few more questions about (TIME WHEN DRINKING THE MOST OR HAD PROBLEMS).

More information

Treatments for drug misuse

Treatments for drug misuse Understanding NICE guidance Information for people who use NHS services Treatments for drug misuse NICE clinical guidelines advise the NHS on caring for people with specific conditions or diseases and

More information

YELDALL MANOR APPLICATION FORM

YELDALL MANOR APPLICATION FORM YELDALL MANOR APPLICATION FORM The information given on this form will not be passed to anyone else, except where this is necessary to process your application. Please write clearly and complete as much

More information

Iowa Governor s Office of Drug Control Policy

Iowa Governor s Office of Drug Control Policy Iowa Governor s Office of Drug Control Policy medicines or take them in a manner not prescribed, we increase the risk of negative effects. It is estimated that over 35 million Americans are ages 65 and

More information

Alcohol Addiction. Introduction. Overview and Facts. Symptoms

Alcohol Addiction. Introduction. Overview and Facts. Symptoms Alcohol Addiction Alcohol Addiction Introduction Alcohol is a drug. It is classed as a depressant, meaning that it slows down vital functions -resulting in slurred speech, unsteady movement, disturbed

More information

Medication Allergies and Reactions: Please do not leave blank, write none if no allergies.

Medication Allergies and Reactions: Please do not leave blank, write none if no allergies. Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you the best possible care. Today

More information

Give Your Baby a Healthy Start

Give Your Baby a Healthy Start The dangers of smoking, drinking, and taking drugs Give Your Baby a Healthy Start Tips for Pregnant Women and New Mothers What you do today can stay with your baby forever Your baby needs your love and

More information

Standards of Conduct

Standards of Conduct Standards of Conduct The unlawful manufacture, distribution, dispensation, possession, or use of illicit drugs or alcohol by students or employees of Auburn University is prohibited at any time on any

More information

- UNDERSTANDING - Dual Diagnosis

- UNDERSTANDING - Dual Diagnosis - UNDERSTANDING - Dual Diagnosis TABLE OF CONTENTS Introduction 3 The Link Between Mental Illness and Substance Abuse 4 Characteristics of an Effective Dual Diagnosis Treatment Plan 6 Dual Diagnosis Treatment

More information

Outline. Drug and Alcohol Counseling 1 Module 1 Basics of Abuse & Addiction

Outline. Drug and Alcohol Counseling 1 Module 1 Basics of Abuse & Addiction Outline Drug and Alcohol Counseling 1 Module 1 Basics of Abuse & Addiction About Substance Abuse The Cost of Chemical Abuse/Addiction Society's Response The Continuum of Chemical Use Definitions of Terms

More information

Recovery Center Outcome Study

Recovery Center Outcome Study Findings from the Recovery Center Outcome Study 2013 Report Page 1 TABLE OF CONTENTS EXECUTIVE SUMMARY...3 INTRODUCTION AND OVERVIEW... 6 SECTION 1: CLIENT SATISFACTION WITH RECOVERY CENTER PROGRAMS...

More information

SANTA FE COLLEGE DRUG AND ALCOHOL ABUSE PREVENTION PROGRAM

SANTA FE COLLEGE DRUG AND ALCOHOL ABUSE PREVENTION PROGRAM SANTA FE COLLEGE DRUG AND ALCOHOL ABUSE PREVENTION PROGRAM In compliance with Federal law, 20 USC 1011i and 34 CFR 86.100(a), Santa Fe College has adopted and implemented a drug and alcohol abuse prevention

More information

Teens and Prescription Drug Abuse

Teens and Prescription Drug Abuse Teens and Prescription Drug Abuse Information compiled by Communities That Care of Lorain County For more information, please contact Cathy Gabe 440-282-9920 cgabe@lorainadas.org www.ctcloraincounty.org

More information

1. Your grade level Response Percent

1. Your grade level Response Percent 1. Your grade level 9 29% 74 10 23.9% 61 11 28.2% 72 12 18.8% 48 Respondents 255 (filtered out) 213 (skipped this question) 0 2. Your Gender Female 100% 255 Male 0% 0 Respondents 255 (filtered out) 213

More information

Let s talk about Eating Disorders

Let s talk about Eating Disorders Let s talk about Eating Disorders Dr. Jane McKay Dr. Ric Arseneau Dr. Debbie Rosenbaum Dr. Samantha Kelleher Dr. Julia Raudzus Role of the Psychiatrist Assessment and diagnosis of patients with eating

More information