Your Company 123 Company Ave. Philadelphia PA (215) COMPARISON REPORT. John B Smith

Transcription

1 Your Company 123 Company Ave Philadelphia PA (215) COMPARISON REPORT FICTITIOUS CLIENT The following is a report of 's baseline Addiction Severity Index information collected on compared to Addiction Severity Index information provided during the follow-up interview on. Client Information & Demographics Client ID: SM Birth Date: 07/30/1969 Gender: Male Race: White Ethnicity: Not Hispanic or Latino Religious Preference: Catholic Current Address: 444 Main St Philadelphia, PA General Information Controlled Environment G19. Controlled Environment in the past 30 days: Jail No G20. How many days: 2 N Medical Status Medical History M1. Times hospitalized for medical problems: 1 0* M4. Taking prescribed medications regularly: Yes Yes Inhaler; client's medication is Asthma Inhaler - Prescribed prescribed not over the counter M5. Receives pension for physical disability: No No Client Perception of Medical Problem Severity and Desire for Treatment M6. Days of medical problems in the past 30: 0 2 M7. How troubled or bothered by medical problems: Not at all Slightly M8. How important is treatment for medical problems: Not at all Slightly M10. Patient's misrepresentation: No No *Note: Time period for intake data is "lifetime", while Follow-up data is based on past 6 months. Page 1 of 7

2 M11. Patient's inability to understand: No No *Note: Time period for intake data is "lifetime", while Follow-up data is based on past 6 months. Page 2 of 7

3 Employment/Support Status Education, Training & Resources E1. Education completed: 14 yr, 0 mo 0 mo* E2. Training/technical education completed: 12 mo 0 mo* E4. Valid driver's license: Yes No E5. Automobile available for use: No No Current Financial Resources E7. Usual (or last) occupation: 5. Skilled manual/electrician 5. Skilled manual/electrician* Specified in detail Foreman construction Foreman at construction company company E8. Someone contributes to client's support: No No E9. Does this constitute the majority of your support? N/A N/A E11. Days paid for working in the past 30: Money received in the past 30 days: E12. Employment (Net Income): $ 7200 $ 7200 E13. Unemployment Compensation: $ 0 $ 0 E14: Welfare: $ 0 $ 0 E15: Pension, Benefits or Social Security: $ 0 $ 0 E16. Mate, Family or Friends: $ 0 $ 0 E17. Illegal: $ 0 $ 0 E18. Number of people who depend on client: 4 4 Client Perception of Employment Problem Severity and Desire for Treatment E19. Days of employment problems in the past 30: 0 3 E20. How troubled or bothered by employment problems: Not at all Slightly E21. How important is treatment for employment problems: Not at all Slightly E23. Patient's misrepresentation: No No E24. Patient's inability to understand: No No *Note: Time period for intake data is "lifetime", while Follow-up data is based on past 6 months. Page 3 of 7

4 Drug/Alcohol Use Past 30 Days Use & Route of Administration (ROA) D1. Alcohol - any use at all: 20/Oral 2/Oral D2. Alcohol - to intoxification: 20/Oral 2/Oral D3. Heroin: 8/IV 0/N/A D4. Methadone: 2/Oral 0/N/A D5. Other Opiates/Analgesics: 0/N/A 0/N/A D6. Barbiturates: 0/N/A 0/N/A D7. Other Sedatives/Hypnotics/Tranquilizers: 0/Oral 0/N/A D8. Cocaine: 3/Nasal 0/N/A D9. Amphetamines: 0/N/A 0/N/A D10. Cannabis: 10/Smoking 2/Smoking D11. Hallucinogens: 0/N/A 0/N/A D12. Inhalants: 0/N/A 0/N/A D13. More than one substance per day: 20 0 D14. Substance which is major problem: Alcohol & one or more drugs X Number of Times: D17. Had Alcohol D.T.'s 0 0* D18. Overdosed on drugs: 0 0* Treatment History & Money Spent D19. Number of times treated for alcohol use: 2 0* D21. Number of alcohol detox only: 0 N* D20. Number of times treated for drug use: 2 0* D22. Number of drug detox only: 0 N* D23. Money spent on Alcohol during the past 30 days: $ 100 $ 15 D24. Money spent on Drugs during the past 30 days: $ 300 $ 20 D25. Number of days treated in an outpatient setting: 4 4 Client Perception of Alcohol & Drug Problem Severity and Desire for Treatment D26. Days of Alcohol problems in the past 30: 30 2 D28. How troubled or bothered by Alcohol problems: Considerably Moderately D30. How important is treatment for Alcohol problems: Extremely Moderately D27. Days of Drug problems in the past 30: 10 2 D29. How troubled or bothered by Drug problems: Considerably Moderately D31. How important is treatment for Drug problems: Extremely Moderately D34. Patient's misrepresentation: No No D35. Patient's inability to understand: No No *Note: Time period for intake data is "lifetime", while Follow-up data is based on past 6 months. Page 4 of 7

5 Legal Status History of Charges & Arrests L2. Client on Probation or Parole: No No Number of times client arrested and charged with: L3. Shoplifting/Vandalism: 0 0* L4. Parole/Probation Violations: 0 0* L5. Drug Charges: 2 0* L6. Forgery: 0 0* L7. Weapons Offense: 0 0* L8. Burglary, Larceny, B&E: 1 0* L9. Robbery: 0 0* L10. Assault: 0 0* L11. Arson: 0 0* L12. Rape: 0 0* L13. Homicide, Manslaughter: 0 0* L14. Prostitution: 0 0* L15. Contempt of Court: 0 0* L16. Other: 0 0* L17. Number of these charges resulted in convictions: 1 N* Number of times client charged with: L18. Disorderly Conduct/Vagrancy/Public Intoxication: 1 0* L19. Driving While Intoxicated: 2 0* L20. Major Driving Violations: 0 0* L21. Number of months incarcerated: 3 0* Current Legal Involvement L24. Presently awaiting charges, trial or sentence: Yes No L25. What for: L19. Driving while N intoxicated Number of days in past 30: L26. Client was detained or incarcerated: 2 0 L27. Client engaged in illegal activities for profit: 0 0 Client Perception of Legal Problem Severity and Desire for Treatment L28. How serious client rates present legal problems: Slightly Not at all L29. How important is counseling/referral for problems: Not at all Not at all Interviewer Confidence Rating L31. Patient's misrepresentation: No No L32. Patient's inability to understand: No No *Note: Time period for intake data is "lifetime", while Follow-up data is based on past 6 months. Page 5 of 7

6 Family/Social Relationships Marital & Living Situation F1. Marital Status: Divorced Divorced F3. Satisfied with this situation: Yes Yes F4. Usual Living Arrangements: Alone Alone* F6. Satisfied with these arrangements: Indifferent Yes Recovery Environment & Social Contacts F9. Client spends most of free time with: Alone Family F10. Satisfied with spending free time this way: No Yes F11. Number of client's close friends: 4 4 Relationship Problems Past 30 Days In past 30 days, experienced serious problems getting along with: F18. Mother No No F19. Father No No F20. Brothers/Sisters: No No F21. Sexual Partner/Spouse: Yes No F22. Children: No No F23. Other Significant family: No No F24. Close Friends: No No F25. Neighbors: No No F26. Co-Workers: No No Client Perception of Family & Social Problem Severity and Desire for Treatment F30. Days of serious conflicts with Family in past 30: 10 0 F32. How troubled or bothered by Family problems: Considerably Not at all F34. How important is treatment/counseling for Family problems: Extremely Not at all F31. Days of serious conflicts with Other People in past 30: 0 0 F33. How troubled or bothered by Social Problems: Not at all Not at all F35. How important is treatment/counseling for Social Problems: Not at all Not at all F37. Patient's misrepresentation: No No F38. Patient's inability to understand No No *Note: Time period for intake data is "lifetime", while Follow-up data is based on past 6 months. Page 6 of 7

7 Psychiatric Status Treatment for Emotional and Psychological Problems Number of times treated for psychological/emotional problems: P1. In a Hospital: 0 0* P2. As an Outpatient or Private Patient: 0 0* P3. Client receives a pension for a psychiatric disability: No No Recent Serious Emotional and Psychological Problems In the past 30 days, there were significant periods in which client: P4. Experienced serious depression: Yes Yes P5. Experienced serious anxiety or tension: No Yes P6. Experienced hallucinations: No No P7. Experienced trouble understanding, remembering, etc.: No No P8. Experienced trouble controlling violent behavior: Yes No P9. Experienced serious thoughts of suicide: No No P10. Attempted suicide: No No P11. Been prescribed medication for psychological problem: No No Client Perception of Emotional and Psychological Problem Severity and Desire for Treatment P12. Days of psychological/emotional problems in past 30: 4 5 P13. How troubled or bothered by psychological problems: Slightly Slightly P14. How important is treatment for psychological problems: Slightly Slightly Interviewer Impressions At the time of the interview, the patient is: P15. Obviously depressed/withdrawn: No No P16. Obviously hostile: No No P17. Obviously anxious/nervous: No No P18. Having trouble with reality testing, thought disorders, etc.: No No P19. Having trouble comprehending, remembering, etc.: No No P20. Having suicidal thoughts: No No P22. Patient's misrepresentation: No No P23. Patient's inability to understand: No No *Note: Time period for intake data is "lifetime", while Follow-up data is based on past 6 months. Page 7 of 7