Patient Assessment

The following assessment is part of the process of beginning to understand how your experiences and the disease of addiction have impacted your life. The information provided in this assessment is completely confidential. We will use this tool to help guide our conversations around what would be the next best step for your recovery. Our priority is helping you find the support that you deserve so that you can continue to Stay Clean. Thank you for completing the assessment. We look forward to working with you.

Let's Get Started!

Patient Name:

Email:

Office Location:

A. Background, Environment, and Social Risk Factors

1. What is your age?

2. Are you currently in a stable, committed relationship? Yes No

3. Rate the amount of stress in your current relationship. (1- very little stress; 5- high stress)

4. Are you currently living with anyone who is using drugs? Yes No

5. Do you have a relationship (friends, family, etc.) with anyone who regularly attends Al-Anon or Nar- Anon meetings? Yes No

6. Are you currently employed? Yes No

7. Are there people in your work environment who are currently using alcohol or other drugs? Yes No

8. Do you have insurance that will cover inpatient rehab, outpatient rehab, or counseling resources? Yes No Unknown

9. Do you have the financial resources to pay out of pocket for rehabilitation or counseling resources? Yes No

10. Do you currently have access to personal transportation? Yes No

Total

B. Severity of Drug Use

1. Have you ever abused your pain killers (as opposed to only using them as directed, under a doctor's prescription)? Yes No

2. How many years have you been abusing opiates?

3. Have you ever snorted opiates? Yes No

4. Have you ever injected opiates? Yes No

5. Have you ever used more than $100 of opiates in one day? Yes No

6. Have you recently (within the past year) made any money from supplying opiates to others? Yes No

7. How many times have you overdosed on opiates?

8. How many times have you been incarcerated for drug and/or alcohol-related incidences?

Total

C. Alcohol and/or Other Drug Use

1. Are you drinking alcohol more than once a week? Yes No

2. In the last 30 days, how many times did you drink alcohol to the point of intoxication?

3. Has anyone ever told you that you have a drinking problem? Yes No

4. How many DUI/DWI's (Driving Under the Influence) have you had?

5. Have you ever considered yourself an alcoholic? Yes No

6. In the last year, have you used cocaine? Yes No

7. Have you ever had a problem with cocaine? Yes No

8. In the last year, have you used any amphetamines (speed)? Yes No

9. Have you ever had a problem with amphetamines (speed)? Yes No

10. In the last year, have you used benzodiazepines? Yes No

11. Have you ever been dependent on benzodiazepines? Yes No

12. Are you currently dependent on benzodiazepines? Yes No

13. Have you smoked marijuana in the last year? Yes No

14. Have you ever smoked marijuana on a daily basis? Yes No

15. Are you currently smoking marijuana once a week or more? Yes No

Total

D. Mental Health History

1. Are you or would you be comfortable participating in group therapy? Yes No

2. Do you have trouble controlling your anger? Yes No

3. Have you ever experienced depression? Yes No

4. Are you currently prescribed any psychiatric medications? Yes No

5. Have you ever been diagnosed with Bipolar Disorder? Yes No

6. Have you ever been diagnosed with a Personality Disorder (i.e. Borderline Personality Disorder, Narcissistic Personality Disorder, etc.) Yes No

7. Have you ever been diagnosed with Post Traumatic Stress Disorder? Yes No

8. Have you ever experienced significant anxiety? Yes No

9. Have you ever been admitted to a psychiatric hospital for reasons not drug-related? Yes No

10. Have you ever experienced abuse of any kind? (physical, emotional, or mental) Yes No

Total

E. Childhood Experiences

1. Did a parent or other adult in the household often or very often ...
Swear at you, insult you, put you down, or humiliate you? or
Act in a way that made you afraid that you might be physically hurt? Yes No

2. Did a parent or other adult in the household often or very often ... Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Yes No

3. Did an adult or person at least 5 years older than you ever ... Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? Yes No

4. Did you often or very often feel that ... No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other? Yes No

5. Did you often or very often feel that ... You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No

6. Were your parents ever separated or divorced? Yes No

7. Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? Yes No

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No

9. Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes No

10. Did a household member go to prison? Yes No

Total

F. Level of Motivation to Change

Please rate each question on a scale of 1-5. A rating of 1 = low ; a rating of 5 = high.

1. How severe do you perceive your drug problem to be?

2. How difficult do you think it will it be for you to stay off of drugs?

3. How motivated are you to abstain from using opiates?

4. How motivated are you to abstain from drinking alcohol?

5. How motivated are you to abstain from smoking marijuana?

6. How motivated are you to abstain from using any other drugs?

7. How motivated are you to use Naltrexone for 12 months?

8. How interested are you in getting involved with and AA or NA program?

9. How willing are you to give up your using friends?

10. How willing are you to go to a 28-30 day treatment program?

11. How willing are you to live in a recovery residence for 12 months if necessary to stay off of drugs forever?

Total

G. Experience With Recovery

1. Have you ever completed a 30-day inpatient treatment program? Yes No

2. How long did you stay clean after completing the program?

3. Have you ever completed an IOP program? Yes No

4. How long did you stay clean after completing the program?

5. What is the longest you have ever stayed off of drugs (discounting any jail time)?

6. How many 12 step meetings have you ever attended?

8. Have you ever completed a 4th step? Yes No N/A

9. Have you ever had a sponsor? Yes No N/A

10. Have you ever been in individual therapy? Yes No N/A

11. Do you know what CBT or REBT is? Yes No N/A

Total

Patient Assessment

Thank you for completing the assessment. Results will be emailed to you shortly.