Various models of substance abuse prevention, intervention, and rehabilitation are available for the delivery of support services for justice-involved individuals with addiction and substance abuse is
CPSS/420 v2
Intake Assessment Form
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 InformationClient’s First Name:
Client’s Last Name:
Date of Birth:
Insurance Type:
Client’s Preferred Name:
Admission Date:
Emergency Contact InformationEmergency 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 BirthMention ‘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 IdentityMention ‘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 PreferredMention ‘Yes’ against what is relevant:
Him:
Her:
They:
Other:
Unknown:
Referral ReasonWhy has the client been referred?
Treatment counselor:
Alcohol and Drug HistoryFill 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 |
| Medical Provider | Name: | Phone #: | Last Date of Service: |
| Primary Physician: | |||
| Other medical provider(s) |
Date records requested:
From whom, if applicable:
Relevant Medical HistoryGeneral 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 | |||||||||
| Heartburn | |||||||||
| Diarrhea | |||||||||
| Constipation | |||||||||
| Nausea | |||||||||
| Vomiting | |||||||||
| Ulcers | |||||||||
| Pancreatitis | |||||||||
| Headache | |||||||||
| TBI/LOC | |||||||||
| Seizures | |||||||||
| Memory | |||||||||
| Concentration | |||||||||
| Back pain | |||||||||
| Broken bones | |||||||||
| Arthritis | |||||||||
| Mobility issues | |||||||||
| Pregnant | |||||||||
| STD | |||||||||
| Menopause | |||||||||
| Scar | |||||||||
| Lesion | |||||||||
| Lice | |||||||||
| Dermatitis | |||||||||
| Burns | |||||||||
| Diabetes | |||||||||
| Thyroid | |||||||||
| Significant accident | |||||||||
| Injuries | |||||||||
| Surgeries | |||||||||
| Hospitalizations | |||||||||
| Physical disability | |||||||||
| Chronic illness | |||||||||
| HIV | |||||||||
| Liver disease |
Write details against what is relevant:
Significant accident
Injuries:
Surgeries:
Hospitalizations:
Physical disability:
Chronic illness:
HIV:
Liver disease:
Alternative healing practice/dateFor example, acupuncture, herbs, supplements, etc.
Current/ Previous Medications(Include all prescribed, OTC, holistic/alternative remedies)
Allergies/Adverse Reactions/ Sensitivities:
Food:
Drugs (Rx/OTC/ILLICT):
Unknown:
Other:
Date of last physical exam:
Date of last dental exam:
Referral made to primary care or specialty (Yes or No. If yes, list):
Additional Medical Information:
Mental Health History Psychiatric HospitalizationsYes or No:
Outpatient TreatmentYes or No:
Risk factorsMention ‘Yes’ against what is relevant:
Aggressive/Violent Behaviors:
Self-Harm:
Client referred to crisis services line:
Mental health disorders that are pre-existing, contribute to substance use/abuse, or have been exacerbated by substance use:
Psychosocial HistoryFamily problems that are contributing to, or are exacerbated by, substance abuse. Mention ‘Yes’ against what is relevant and describe below:
Arguments:
Domestic violence:
Family abuses alcohol/drugs:
Family worried about client’s use of drugs/alcohol:
Separated or divorced:
Describe Problems Contributing to Substance Abuse
Highest level of education completed:
Client currently employed? (Yes/ No):
If so, list employer and job:
Problems Caused by Substance Abuse:
Add “Yes” after anything substance use/abuse has caused or contributed to:
Absenteeism:
Tardiness:
Accidents:
Working while hung-over:
Trouble concentrating:
Decreased job performance:
Consumed substances while at work:
Lost job due to substance abuse:
No work problem:
Comments:
Criminal History/Legal StatusCriminal History Table
Legal Status Table
Other:
Describe criminal justice involvement.
Note: More space is provided in the Addendum
Describe any relevant family involvement with criminal justice.
Note: More space is provided in the Addendum
Personal HistoryWrite ‘Not Applicable’ if not applicable.
Client currently in a relationship? If yes, list length or other comments below:
History of sexual abuse?
History of physical abuse?
Does client have children? If yes, list age of each below:
Child 1:
Child 2:
Child 3:
Child 4:
Child 5:
Describe assessed knowledge of parenting skills.
Describe assessed education/knowledge of harmful effects that alcohol and drugs have on the caregiver and fetus, or caregiver and infant.
List parenting skills most needed.
Does client need or will client receive childcare? Answer yes or no:
Client needs to access the following ancillary services which are medically necessary. Provide comments below: (Mention ‘Yes’ against what is relevant)
Dental services:
Social services:
Community services:
Educational/Vocational training:
Transportation (or arranging for) to and from medically necessary treatment:
Other: Specify:
Clinical FormulationInstructions: Consider all information gathered in the intake assessment for the treatment plan formulation. The formulation should identify each problem that is contributing to client’s alcohol or substance use disorder. All issues identified during the intake assessment process must be listed as a problem statement on the treatment plan (SMART goals). However, some problem statements can de deferred as determined appropriate by the treatment staff.
AddendumUse this area to report additional criminal justice involvement, etc.
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