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(PAIP) Partner Abuse Intervention Program
Substance Abuse Evaluations / Treatment
DUI Classes/Treatment
DUI Evaluations for Secretary of State
Anger Management Classes
Parenting Classes
Mental Health Evaluations
About Us
Home
(PAIP) Partner Abuse Intervention Program
Substance Abuse Evaluations / Treatment
DUI Classes/Treatment
DUI Evaluations for Secretary of State
Anger Management Classes
Parenting Classes
Mental Health Evaluations
About Us
Individual Counseling Intake Screening
Home
Individual Counseling Intake Screening
INDIVIDUAL COUNSELING
Please complete all information. It may seem long, but most of the questions require only a check, so it will go quickly. This form is required for your initial intake appointment. Call us if you have any questions (773) 293-1770. Thank you
Enter Today's Date
(Required)
Month
Day
Year
Name
(Required)
First
Middle
Last
Birthdate:
(Required)
Month
Day
Year
Phone
(Required)
Email
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Who is your Probation Officer or Case Worker?
What is their Phone Number?
Do you have their Email?
Occupational History:
Working
Student
Unemployed
Disabled
Retired
How long in present position?
Have you ever served in the military?
YES
NO
Criminal History
If you were referred by court, describe the arrest or your current court case.
How many Times have you been arrested as an Adult?
Describe your past criminal history. Please include past convictions, court probation, supervision, parole, or sentences.
Alcohol and Drug Use History
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
NO
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
None
Marijuana
Cocaine
Amphetamines
Barbiturates
Base Cocaine
Benzodiazepines
Crack
Dilaudid (RX/Non RX)
Hallucinogens other (Peyote, LSD, etc.)
Hashish
Heroin
Inhalants
Karachi
Methamphetamines
Nicotine
Non RX Methadone
Non-Barbiturate Sedatives
Other Opioids
Over the Counters
PCP
Other
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
None
Marijuana
Cocaine
Amphetamines
Barbiturates
Base Cocaine
Benzodiazepines
Crack
Dilaudid (RX/Non RX)
Hallucinogens other (Peyote, LSD, etc.)
Hashish
Heroin
Inhalants
Karachi
Methamphetamines
Nicotine
Non RX Methadone
Non-Barbiturate Sedatives
Other Opioids
Over the Counters
PCP
Other
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.
3. Drug
None
Marijuana
Cocaine
Amphetamines
Barbiturates
Base Cocaine
Benzodiazepines
Crack
Dilaudid (RX/Non RX)
Hallucinogens other (Peyote, LSD, etc.)
Hashish
Heroin
Inhalants
Karachi
Methamphetamines
Nicotine
Non RX Methadone
Non-Barbiturate Sedatives
Other Opioids
Over the Counters
PCP
Other
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.
4. Drug
None
Marijuana
Cocaine
Amphetamines
Barbiturates
Base Cocaine
Benzodiazepines
Crack
Dilaudid (RX/Non RX)
Hallucinogens other (Peyote, LSD, etc.)
Hashish
Heroin
Inhalants
Karachi
Methamphetamines
Nicotine
Non RX Methadone
Non-Barbiturate Sedatives
Other Opioids
Over the Counters
PCP
Other
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.
5. Drug
None
Marijuana
Cocaine
Amphetamines
Barbiturates
Base Cocaine
Benzodiazepines
Crack
Dilaudid (RX/Non RX)
Hallucinogens other (Peyote, LSD, etc.)
Hashish
Heroin
Inhalants
Karachi
Methamphetamines
Nicotine
Non RX Methadone
Non-Barbiturate Sedatives
Other Opioids
Over the Counters
PCP
Other
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.
NEXT SECTION
Have you ever experienced the following as a result of your alcohol/drug use?
1. Missed work
YES
NO
2. Under the influence of alcohol/drugs during work
YES
NO
3. Under the influence of alcohol/drugs before noon
YES
NO
4. Gulped drinks
YES
NO
5. Hidden alcohol/drugs in the home from parents or partner
YES
NO
6. Experienced memory loss of events that occurred during intoxication
YES
NO
7. Passed out
YES
NO
8. Become sick (headaches, hangovers, upset stomach, vomiting, etc.)
YES
NO
9. Been in a fight
YES
NO
10. Had close friends or relatives express concern over drinking/drug use
YES
NO
11. Set out with the thought of having a social drink but became intoxicated
YES
NO
12. Lost friends or had relationships break up over alcohol/drug use
YES
NO
13. Felt annoyed when confronted with possible alcohol/drug problem
YES
NO
14. Felt guilty or ashamed of things said or done while drinking/using drugs
YES
NO
15. Tried to quit drinking/using drugs but failed
YES
NO
16. Experienced extreme personality changes when drinking/using drugs
YES
NO
17. Noticed increased tolerance to alcohol or other drugs
YES
NO
18. Used alcohol to self-medicate chronic pain
YES
NO
19. Experienced shakes or tremors
YES
NO
EMOTIONAL, BEHAVIORAL OR COGNITIVE CONDITIONS AND COMPLICATIONS
Have you ever or currently been diagnosed with a Psychiatric and/or Psychological Condition?
YES
NO
If yes, describe:
Are you under the care of a Psychiatrist?
YES
NO
Have you ever been treated by a mental health professional?
YES
NO
If yes, describe:
In the last 12 months, have you experienced problems with any of the following difficulties or symptoms?
Sleep disturbances
Mood swings
Nervousness
Restlessness
Mental confusion
Sadness
Irritability
Preoccupations
Violent thoughts
Loss or increase of sexual interest
Isolation
Apathy
Obsessions
Fear
Have you ever experienced Hallucinations?
YES
NO
Have you ever experienced Delusions/False Thoughts?
YES
NO
If Yes, Describe:
Have you ever had an attempt or plan of suicide?
YES
NO
If Yes, Describe:
Have you ever had feelings or thoughts that you didn't want to live? If YES, please answer the following. If NO, please skip to the next section
YES
NO
Do you currently feel that you don't want to live?
YES
NO
Trouble falling or staying asleep, or sleeping too much
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
When was the last time you had thoughts of dying?
Has anything happened recently to make you feel this way?
Do you feel hopeless and/or worthless?
YES
NO
If Yes, Describe:
DEPRESSION SCREEN: Over the last 2 weeks, how often have you Not Several half the Nearly been bothered by any of the following problems?
Little interest or pleasure in doing things.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Feeling down, depressed, or hopeless.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Feeling tired or having little energy.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Poor appetite or overeating.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Feeling bad about yourself—or that you are a failure or have let yourself or your family down.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Trouble concentrating on things such as reading the newspaper or watching television.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
How difficult have these problems made it for you to do your work, take care of things at home or get along with other people? (please circle one)
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Thoughts that you would be better off dead or of hurting yourself in some way.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Anxiety Screen: Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling nervous, anxious or on edge.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Not being able to stop or control worrying.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Worrying too much about different things.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Troubling relaxing.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Being so restless that it is hard to sit still.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Becoming easily annoyed or irritable.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
Feeling afraid as if something awful might happen.
NOT AT ALL
SEVERAL DAYS
MORE THAN HALF THE DAYS
NEARLY EVERYDAY
I have been exposed to actual or threatened death, serious injury or sexual violence.
YES
NO
I have intense memories of a previous traumatic event.
YES
NO
I try to avoid people, places or things associated with a traumatic event.
YES
NO
My thoughts and moods have been negatively impacted by a traumatic event.
YES
NO
I feel numb, detached or isolated from others.
YES
NO
I have mood swings that seem to come out of nowhere.
YES
NO
Have you been exposed to Domestic Violence?
YES
NO
Have you ever experienced any of the following?
Emotional abuse
Physical abuse
Sexual abuse
Neglect
Please describe when, where, and by whom:
PERSONAL SITUATION
Relationship History and Current Family:
Married
Partnered
Divorced
Single
Widowed
If not married, are you currently in a relationship?
YES
NO
Are you sexually active?
YES
NO
How would you identify your sexual orientation?
What is your spouse or significant other's occupation?
Describe your relationship with your spouse or significant other:
Do you have children?
YES
NO
f yes, list their ages and gender:
List everyone who currently lives with you:
Are your parents alive and well?
YES
NO
Describe your relationship with your parents. Were there any issues or problems with your parents' relationship as you were growing up:
Spiritual Life: Do you belong to a particular religion or spiritual group?
YES
NO
If yes, what is the level of your involvement?
What are some of your personal hobbies?
Other comments or concerns:
RELEASE OF INFORMATION FORM
AUTHORIZATION FOR RELEASE OF INFORMATION
(Required)
I agree to the privacy policy.
I Authorize the mutual release of information between the below stated program and Avance, Inc. at 2601 W. Lawrence Ave. Chicago, IL, 60625, Phone: (773) 293-1770.
The purpose of this release is: Partner Abuse Interventions
The extent, type, and nature of the information or records to be disclosed:
• Attendance record
• Evaluation Results and Recommendations
• Monthly reports
• Type, frequency, and effectiveness of treatment
• Discharge summary
• General adjustments to program rules
• Prognosis
• Date and reason for withdrawal from program
The date, event, or condition upon which this consent will expire without my express revocation shall be one year from today’s date, which is of duration no longer than that reasonably necessary to effectuate the purpose for which this consent is given.
By consenting to this form, I understand that my records are protected by Federal Confidentiality Regulation (42 CFS Part 2) and cannot be disclosed without my written consent at any time except to the extent that disclosure was made prior to the time I revoked it. I further understand that disclosure includes the right of the recipient to inspect and receive a copy of the information to be disclosed. This release will remain valid for a period of one year.
CLIENT'S CONSENTS FORM
CONSENT FORM
(Required)
I AGREE TO THE CONSENT FORM.
I hereby give my consent to Avance, Inc. to provide the Partner Abuse Intervention Program (PAIP) and collect my personal information for the purpose of this intake.
In addition, Informed Consent means that I am:
• Informed of my legal rights as a patient.
• Informed of my responsibilities, including conformity to program rules and regulations.
• Informed of how I am protected under the rules of confidentiality from disclosure of information I have not authorized.
I certify that I have read, or the information has been read to me, and I fully understand the contents of this consent for assessment and treatment.
CLIENT'S RIGHTS FORM
PATIENT RIGHTS STATEMENT
I AGREE TO THE PATIENT RIGHTS STATEMENT.
PATIENT RIGHTS STATEMENT
In seeking services from AVANCE, Inc., I have the following rights:
1. Access to services will not be denied on the basis of race, religion, ethnicity, disability, sexual orientation, or HIV status.
2. Services will be provided in the least restrictive environment available.
3. Confidentiality of HIV/AIDS status as specified in Section 2060.321 of the administrative rule.
4. The right to nondiscriminatory access to services as specified in the American’s with Disabilities Act of 1990 (42 USC 121001).
5. The right to give or withhold informed consent regarding treatment and regarding confidential information about myself.
6. A description of the route of appeal available if I disagree with the organization’s decision or policies.
7. Any complaints must be addressed directly to your assigned counselor. If the issue is unresolved, you must contact the director of Avance, Jorge Argueta. If the issue continues to be unresolved, contact Ivan Zdero at (847) 346-7900.
8. Confidentiality of patient records as specified in Section 2060.319 of the Part.
9. The right to refuse treatment or any specific treatment procedure and a right to be informed of the consequences resulting from such refusal.
I certify that I have read my legal rights as a client at Avance.
REIMBURSEMENT POLICY FORM
REIMBURSEMENT POLICY
I agree to the privacy policy.
NO REIMBURSEMENT POLICY
REINSTATEMENT FEE DUE TO TERMINATION
I understand that Avance, Inc. will not reimburse any fees paid by me. These fees are NOT reimbursed even if I decide not to return to complete the program. The payment made today covers the cost of the intake or assessment and is NOT reimbursable.
I also understand that if I am TERMINATED from the program, I need to pay an administrative/reinstatement fee in order to resume my treatment at Avance, Inc. and to cover the costs of the continuing care review and/or additional intake/screening documentation.
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