Substance Abuse Intake Questionnaire

Thank you for contacting Avance. Please fill out this Intake Questionnaire to complete the Substance Abuse Evaluation. One of our counselors will review these documents. We will also call you to schedule an appointment for an interview and to discuss the results of the evaluation.

SUBSTANCE ABUSE SCREENING

Enter Today's Date(Required)

Name(Required)

First Last

Birthdate:(Required)

Your Email

Your Phone(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code

What is the name of your Probation Officer or Case Worker?

What is the Phone Number for your Probation Officer or Case Worker?

What is the Email for your Probation Officer or Case Worker?

Do you give us authorization to release a letter of compliance and monthly reports to your referral source?(Required)

YES

Emergency Contact?

First Last

Emergency Contact Phone Number

Number of Dependents (Including Self):

Marital Status

Civil Union

Divorced

Married

Never Married

Separated

Highest level of education

LESS THAN 8TH GRADE

HIGH SCHOOL / GED

COLLEGE GRADUATE

SOME COLLEGE

WORK STATUS

FULL-TIME

PART-TIME

UNEMPLOYED

RETIRED

STUDENT

ANNUAL INCOME

Military Service

YES

Describe the reason/purpose for this evaluation. Tell us about the day of the arrest, or about your DUI arrest. What Happened? Were you intoxicated or under the influence?(Required)

History

How many times have you been arrested for DUI?

Can you describe your past DUI’s? Can you tell us some of the details, for example how much did you drink, or what happened prior and during the arrest?

How many times have you been arrested for Drug Possession or Delivery?

Do you have any other Criminal Arrests?

YES

If yes, describe your past criminal history. Please include past convictions, court probation, supervision, parole, or sentences.

ASAM CRITERIA – DIMENSION 1: Acute Intoxication and/or Withdrawal Potential

How old were you when you first drank alcohol (Beer, Wine, Liquor)?

At what age did you start drinking regularly?

Do you have any tolerance to alcohol?

YES

How many drinks (Beer, Wine, Liquor) do you have to drink to feel the effect of alcohol?

Describe your alcohol history. Tell me from what age to what age, were you drinking the same patterns. For example, "from 25 to 35, I was drinking 4 to 6 beers or drinks 1 time per week, and on special occasions, I drank up to 12 beers" (as an example). Try to be honest, and if you cannot remember try your best to describe your alcohol patterns.

Describe your Alcohol History

How much Alcohol are you drinking currently? Or when was the last time you drank alcohol?

The following section provides a list of drugs. Select the drug or substance that you have used or are currently using. There are 5 options, but only select the drugs that apply to you. if you don't have a drug history go to the next section of this questionnaire.

1. Drug

Describe the drug use history. Tell me the age of first use and the last time you used it. Describe the amounts and times per week, or month, or year when you consumed this substance. Try your best to descrbe the patterns.

2. Drug

3. Drug

4. Drug

5. Drug

NEXT SECTION

Have you ever experienced the following as a result of your alcohol/drug use?

1. Missed work

YES

2. Under the influence of alcohol/drugs during work

YES

3. Under the influence of alcohol/drugs before noon

YES

4. Gulped drinks

YES

5. Hidden alcohol/drugs in the home from parents or partner

YES

6. Experienced memory loss of events that occurred during intoxication

YES

7. Passed out

YES

8. Become sick (headaches, hangovers, upset stomach, vomiting, etc.)

YES

9. Been in a fight

YES

10. Had close friends or relatives express concern over drinking/drug use

YES

11. Set out with the thought of having a social drink but became intoxicated

YES

12. Lost friends or had relationships break up over alcohol/drug use

YES

13. Felt annoyed when confronted with possible alcohol/drug problem

YES

14. Felt guilty or ashamed of things said or done while drinking/using drugs

YES

15. Tried to quit drinking/using drugs but failed

YES

16. Experienced extreme personality changes when drinking/using drugs

YES

17. Noticed increased tolerance to alcohol or other drugs

YES

18. Used alcohol to self-medicate chronic pain

YES

19. Experienced shakes or tremors

YES

ASAM CRITERIA DIMENSION 2: BIOMEDICAL CONDITIONS AND COMPLICATIONS

What is your Height?

What is your current Weight?

How do you rate your current health?

POOR

FAIR

GOOD

EXCELLENT

HISTORY OF HOSPITALIZATIONS (INCLUDING PSYCHIATRIC)

PRESCRIPTIONS AND OVER-THE-COUNTER MEDICATIONS TAKEN IN THE PAST 12 MONTHS

Do you have any physical disabilities?

YES

If yes, please explain:

In the last 12 months, have you experienced any serious medical complications?

YES

If yes, describe:

Have you experienced any of the following in the last six months (check all that apply)?

Do you have a history of any of the following (check all that apply)?

Are you currently pregnant?

YES

Does Not Apply to me (NA)

If yes, are you receiving pre-natal care?

YES

Does Not Apply to me (NA)

Have you used alcohol or drugs during the pregnancy?

YES

Does Not Apply to me (NA)

Have you had any contact with anyone (family/friends) with tuberculosis:

YES

Have you been tested for tuberculosis?

YES

If yes, what were the results of the test:

POSITIVE

NEGATIVE

If positive, did you receive treatment?

YES

Do you have a history of IV drug usage with shared needles?

YES

Have you ever had unprotected sex with multiple sex partners?

YES

ASAM CRITERIA DIMENSION 3: EMOTIONAL, BEHAVIORAL OR COGNITIVE CONDITIONS AND COMPLICATIONS

Have you ever or currently been diagnosed with a Psychiatric and/or Psychological Condition?

YES

If yes, describe:

Are you under the care of a Psychiatrist?

YES

Have you ever been treated by a mental health professional?

YES

If yes, describe:

In the last 12 months, have you experienced problems with any of the following difficulties or symptoms?

Have you ever experienced Hallucinations?

YES

Have you ever experienced Delusions/False Thoughts?

YES

If Yes, Describe:

Have you ever had an attempt or plan of suicide?

YES

If Yes, Describe:

Have you had any current or past suicidal thoughts or gestures?

YES

If Yes, Describe:

Have you made any homicidal attempts against your partner or any other person?

YES

If Yes, Describe:

Do you engage in any types of gambling?

YES

If Yes, Describe:

Have you ever experienced any of the following?

Emotional abuse

Physical abuse

Sexual abuse

Describe:

ASAM CRITERIA DIMENSION 4: READINESS TO CHANGE

Do you have a Problem with Alcohol?

YES

Do you have a Problem with Drugs?

YES

Do you need treatment for Drugs and/or Alcohol?

YES

What is your intention regarding the future use of alcohol/drugs and why?

What are your personal hobbies, activities, interests, and/or coping strategies?

ASAM CRITERIA DIMENSION 5: RELAPSE, CONTINUED USE OR CONTINUED PROBLEM POTENTIAL

If there has been a change in your drinking/drug use pattern since your last DUI or alcohol/drug-related arrest, explain why it has changed:

If you have made a decision to never drink/use drugs again, explain the reason(s) for this decision:

ASAM CRITERIA DIMENSION 6: RECOVERY ENVIRONMENT

Who do you live with?

Have you been in Substance Abuse treatment before?

YES

What was the outcome?

Describe aspects of your childhood that may be relevant or related to the use of drugs or alcohol (e.g., family history of substance use)

Are your friends and family members aware and supportive of your treatment and recovery?

YES

Is anybody in your family affected by drugs and/or alcohol?

YES

Who?

Do you have any close friends that don’t use drugs and/or alcohol?

YES

Have you ever attended AA, NA, CA or other self-help meetings?

YES

Marital status:

Single

Married

Divorced

Separated

Cohabiting

Partner’s first name (only first name):

Is your partner affected by drugs and/or alcohol?

YES

If yes, describe:

Will your partner be supportive of your treatment?

YES

Will he/she be willing to participate in family sessions if necessary?

YES

Do you have children?

YES

Do they live with you?

YES

Are your children affected by your use of drugs and/or alcohol?

YES

If yes, describe:

CONSENT TO RELEASE INORMATION

CONSENT TO ENROLL IN TREATMENT

CLIENT'S RIGHTS

INFORMATION ABOUT COMMUNICABLE DISEASES

READ THE PATIENT EDUCATION PLAN ON COMMUNICABLE DISEASES(Required)(Required)

I READ THE FORM

PATIENT EDUCATION PLAN ON COMMUNICABLE DISEASES

HIV/AIDS
HIV is a virus spread through certain body fluids that attacks the body’s immune system, specifically the CD4 cells, often called T cells. Over time, HIV can destroy so many of these cells that the body can’t fight off infections and diseases. These special cells help the immune system fight off infections. Untreated, HIV reduces the number of CD4 cells (T cells) in the body. This damage to the immune system makes it harder and harder for the body to fight off infections and some other diseases. Opportunistic infections or cancers take advantage of a very weak immune system and signal that the person has AIDS. Learn more about the stages of HIV and how to know whether you have HIV.

TUBERCULOSIS (TB)
Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. Not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions exist: latent TB infection (LTBI) and TB disease. If not treated properly, TB disease can be fatal.

HEPATITIS
Hepatitis refers to inflammation of the liver caused by viruses, bacterial infections, or continuous exposure to alcohol, drugs, or toxic chemicals. There are three forms of the disease:

Hepatitis A is a vaccine-preventable, communicable disease of the liver caused by the hepatitis A virus (HAV). It is usually transmitted person-to-person through the fecal-oral route or consumption of contaminated food or water. Hepatitis A is a self-limited disease that does not result in chronic infection. Most adults with hepatitis A have symptoms, including fatigue, low appetite, stomach pain, nausea, and jaundice, that usually resolve within 2 months of infection; most children less than 6 years of age do not have symptoms or have an unrecognized infection. Antibodies produced in response to hepatitis A infection last for life and protect against reinfection. The best way to prevent hepatitis A infection is to get vaccinated.

Hepatitis B is a liver infection caused by the Hepatitis B virus (HBV). Hepatitis B is transmitted when blood, semen, or another body fluid from a person infected with the Hepatitis B virus enters the body of someone who is not infected. This can happen through sexual contact or through sharing needles, syringes, or other drug-injection equipment. Hepatitis B can also be passed from the mother to baby at birth. For some people, Hepatitis B is an acute, or short-term illness, but for others, it can become a long-term, chronic infection. Risk for chronic infection is related to age at infection: approximately 90% of infected infants become chronically infected, compared with 2%–6% of adults. Chronic Hepatitis B can lead to serious health issues, including cirrhosis or liver cancer. The best way to prevent Hepatitis B is by getting vaccinated.

Hepatitis C is a liver infection caused by the Hepatitis C virus (HCV). Hepatitis C is a blood-borne virus. Today, most people become infected with the Hepatitis C virus by sharing needles or other equipment to inject drugs. For some people, Hepatitis C is a short-term illness, but for 70%–85% of people who become infected with Hepatitis C, it becomes a long-term, chronic infection. Chronic Hepatitis C is a serious disease that can result in long-term health problems, even death. The majority of infected persons might not be aware of their infection, because they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis C is by avoiding behaviors that can spread the disease, especially injecting drugs.

The best protection against these diseases is to avoid high risk activities, including preventing exposure to body fluids of infected persons, always using latex condoms during sex activities, never sharing or using other’s needles, and always washing hands after using the toilet or changing an infant’s diaper.

If you have any questions, please contact your health care provider or local County Health Department.

REIMBURSEMENT POLICY

ORIENTATION FORM

ORIENTATION TO TREATMENT / SERVICES

I agree to this privacy policy.

ORIENTATION TO TREATMENT / SERVICES

I understand that I am enrolling for services at Avance, Inc. and give my consent for outpatient substance abuse and/or DUI treatment. I confirm that my participation in the treatment program is on a voluntary basis. Moreover, I affirm that the intake counselor has informed me of the following:

1. The procedures and treatment that I will receive.

2. The name of my primary counselor and a personal introduction, if possible.

• Counselors’ Names: Jorge Argueta, DBA, MA, CADC; Danny Ponder, CADC, MHP; Eric Matul, MA, LPC, NCC.

The ultimate success of this treatment rests on my willingness to cooperate with the treatment process whereby personal management of honesty, anger, and conflict are all factors that can enhance or limit the treatment process.

I also agree to the following rules and regulations:

1. I will not use any substance (alcohol/drugs) that will in any way alter my mind during the time in which I will be in the program.

2. A counselor at Avance, Inc. may ask me to submit to drug screening and/or a breathalyzer at random. The results of the drug screening and/or breathalyzer may be reported to my referral source, and denial to submit to a drug screening and/or breathalyzer will indicate a stall, which will also be reported to the Circuit Court of Cook County, Secretary of State, or the appropriate referral source(s).

3. I agree to pay for every session that I attend. If I do not pay for 2 consecutive sessions, I understand that any counselor from Avance, Inc. may ask me to leave the group until I pay the remaining balance, according to my financial contract. If a third party pays for the services that Avance, Inc. is providing for me, I am responsible to pay Avance, Inc. any outstanding balance that this third party does not pay. No evaluation, letter, or document about my treatment will be sent to my caseworker, probation officer, or referring source until I update my balance/account.

4. I will comply with the attendance policy, and I also understand that attendance will be reported to the referral source(s). If I am absent for 30 days, my file will be TERMINATED, and a letter of termination will be sent to the referral source(s).

5. I understand that if I can be reinstated to the program, I must pay a $50.00 reinstatement fee. Moreover, I will have to comply with a continuing care evaluation to determine if additional treatment hours / services are needed. Please note that per state policy if I am in the Minimum or Moderate Risk Level I will have to restart the entire program if I fail to maintain consistent attendance.

6. I agree to be on time for each meeting. If I arrive later than 15 minutes from the start of the session, I will not be permitted to attend the meeting, and this will be counted as an absence.

7. I agree to notify the program of any changes in social service, adult probation, and/or referring agency worker. I also agree to notify the program of any home address or telephone number changes.

8. I agree to notify Avance, Inc. of any further police contact, order of protection, or any new charges made against me.

9. Respect to the counselors, staff, and other clients is a condition for an effective treatment outcome. Offensive language and verbal aggression will not be accepted, and you can be suspended if you engage in this behavior.

10. I agree not to use my cell phone or other electronic devices during my scheduled appointments, group sessions, or meetings at Avance, Inc.

11. I understand that Avance, Inc. will report my attendance, any act of violence, and an evaluation of my progress to the social service worker, probation officer, agency, or DCFS worker. I hereby agree that I will make and keep regular appointments scheduled at Avance, Inc. Furthermore, I understand that failure to keep appointments or failure to contact Avance, Inc. in an emergency may result in being suspended from the program.

The following behaviors will result in immediate termination:

• Stealing, destruction/vandalism, and any form of violence. Verbal, physical, and/or threatening behavior will not be tolerated, and it will be reason for immediate discharge from the program.

• Weapons and/or any articles of clothing displaying gang affiliation are prohibited.

I have read and discussed the above information with my intake counselor. I understand the risks and benefits of my treatment at Avance, Inc., the nature and limits of confidentiality, and what is expected of me as a client of Avance, Inc.

QUESTIONS?

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