Tody's Date
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Name
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First Name
Last Name
Email
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Date of Birth
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Phone
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Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
1. Describe presenting problem:
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2. How long have you been experiencing this problem?
3. Rate the intensity of the problem 1 to 5 (1 being mind and 5 being severe):
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4. How is the problem interfering with your day-to-day functioning?
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5. Are you currently or in the last 30 days experienced any of the following symptoms? (check all that apply)
6. Do you now or have you ever contemplated suicide?
7. Are you a survivor of trauma?
8. Are you pregnant now?
9. If yes, when are you due? (day/month/year)
10. Are you at risk for HIV/AIDS/Sexually Transmitted Diseases (unsafe sex, using needles)?
11. Has your physical health kept you from participating in activities?.
12. Please list allergies to medications or food:
1. Current Primary Care Physician:
First Name
Last Name
Primary Care Physician Phone
Country
(###)
###
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2. Past and Current Medical/Surgical Problems:
3. Past and Current Medications and Dosages:
4. Have you seen a Mental Health Professional Before?
If yes, Name, and When:
1. Have you ever used any forms of tobacco (cigarettes, snuff, etc.)? IF NO SKIP TO NEXT SECTION
2. Are you a former tobacco user?
3. If yes, what form(s) of tobacco have you used in the past (please check all that apply)
5. Have you been involved in a program to help you quit using tobacco in the past 30 days?
6. If so, which self-help group was used?
1. Would you or someone you know say you are having a problem with alcohol?
2. Would you or someone you know say you are having problems with pills or illegal drugs?
3. Would you or someone you know say you are having problems with other addictions, ie.gambling, pornography or shopping?
4. Have you ever been to a self-help group?.
1. Would you or someone you know say you had a problem with alcohol?
2. Would you or someone you know say you had problems with pills or illegal drugs?
3. Would you or someone you know say you had problems with other addictions, ie.gambling, pornography or shopping?
4. Is there a family history of addiction in your family?
If yes, please describe:
1. Who is in your family? (parents, brothers, sisters, children, etc.)
2. Has there been any significant person or family member enter or leave your life in the last 90 days?
3. How are the relationships in your family?
4. How are the relationships in your support system (friends, extended family, et.?)
5. Are there any problems in your family now? (check all that apply)
6. Were there any problems with your family in the past? (check all that apply)
7. Are there any problems in your support system now? (check all that apply)
8. Were there any problems with your support system in the past? (check all that apply)
9. What is your marital status now?
10. Have you ever had problems with marriage/relationships?
11. If yes, please check why:
12. Do you have any close friends?
13. Do you have problems with friendships?
14. Do you get along well with others (neighbors, co-workers, etc.)?
15. What do you like to do for fun?
1. What is the highest grad you completed in school? (please check)
2. Would you describe your school experience as positive or negative?
3. Are you currently in school or a training program?
1. Have you ever been arrested? IF NO SKIP TO NEXT SECTION
2. In the past month?
3. If yes, how many times?
4. In the past year?
5. If yes, how many times?
6. If yes, what were you arrested for?
7. What was the name of your attorney?
8. Were you ever sentenced for a crime?
9. If yes, number of prison sentences served?
10. What year(s) did this occur?
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11. Are you currently or have you ever been on probation or parole?
12. If yes, what is the name of your attorney or probation officer?
1. What is your work history like?
2. How long do you normally keep a job?
3. Are you retired?
4. If yes, what kind of work do you do/did you do in the past?
5. Have you ever served in the military?
6. If yes, are you:
Is there anything else you would like me to know about you?
Primary Goals for Sustainable Living
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