18 Jul Review the Intake Assessment Form. Create a fictional history of an inmate or offender who has an alcohol or substance abuse disorder to use for this assignm

CPSS/420 v2

Intake Assessment Form

CPSS/420 v2

Page 2 of 2

Intake Assessment Form

Intake Instructions

Intake staff shall review each completed intake assessment completed for each program participant. The intake assessment may help identify a program participant’s treatment needs, but it is the responsibility of staff to gather additional information in the following areas: Social supports, economic resources (including health insurance or Medicaid availability), the program participant’s family history, education, employment history, criminal history, legal status, medical history, alcohol use and other drug use history, and finally previous treatment programs.

Intake assessments should include the evaluation of substance use disorders; the evaluation of alcohol use disorders, and the assessment of treatment needs. This information is utilized to create client driven, clinically supported treatment plans that are SMART (Specific, Measurable, Attainable, Realist and Timelined)

Client Information

Client’s First Name:

Client’s Last Name:

Date of Birth:

Insurance Type:

Client’s Preferred Name:

Admission Date:

Emergency Contact Information

Emergency Contact:

Relationship:

Contact Address (Street, City, State, Zip):

Contact Phone Number:

Release for Emergency Contact obtained for this time period:

Personal Information

Sex Assigned at Birth

Mention ‘Yes’ against what is relevant:

Male:

Female:

Intersex:

Gender queer:

Gender non-conforming:

Male to female:

Female to male:

Other (Specify):

Unknown or declined to state:

Gender Identity

Mention ‘Yes’ against what is relevant:

Male:

Female:

Intersex:

Gender queer:

Gender non-conforming:

Male to female:

Female to male:

Other:

Unknown or declined to state:

Pronoun Preferred

Mention ‘Yes’ against what is relevant:

Him:

Her:

They:

Other:

Unknown:

Referral Reason

Why has the client been referred?

Treatment counselor:

Alcohol and Drug History

Fill in appropriate details for each.

Check if ever used:	Age at first use:	None or denies	Current Use	Current Abuse	Current Dependence	In Recovery	Client-perceived Problem? Write Y or N
Alcohol
Amphetamines (Speed/Uppers, etc.)
Cocaine/Crack
Opiates (Heroin, Oxy, Methadone, Suboxone)
Hallucinogens (LSD, Mushrooms, Ecstasy, Molly)
Sleeping pills, Benzos, Valium, or similar
PSP (Phencyclidine) or Designer Drugs (GHB)
Inhalants (paint, gas, glue, aerosols)
Marijuana, Hashish. DABS
Tobacco, nicotine, vaping, chew
Caffeine (energy drinks, sodas, coffee, etc.)
Over the counter
Other substances
Complimentary alternative medication

Previous Drug and/or Alcohol Treatment History:

Type of Previous Recovery Treatment (Inpatient, Outpatient, Residential, Detoxification)	Name of Previous Treatment Facility	Dates of Previous Treatment	Treatment Completed (Yes or No)

Medical History:

Medical Provider	Name:	Phone #:	Last Date of Service:
Primary Physician:
Other medical provider(s)

Date records requested:

From whom, if applicable:

Relevant Medical History

General Info:

Baseline weight:

Weight changes:

BP:

Mention ‘Yes’ wherever relevant

Condition	Cardiovascular	Respiratory	Genital, urinary, bladder	Gastro-intestinal bowel	Nervous system	Musculoskeletal	Gyneco logy	Skin	Endocrine
Chest pain
Hypertension
Hypotension
Palpitation
Smoking
Bronchitis
Asthma
COPD
COVID
Incontinence
Nocturia
UTI
Retention
Urgency