Demographic information
Name:
File number:
Referred by:
Date of birth:
Age:
Primary phone:
Primary phone:
Do you allow us to leave message on your phone?
Alternative / Emergency phone number:
Email:
Address:
Postal code:
Family physician:
Psychiatrist:
Relationship/Marital Status:
Single, never married
Married and domestic partnership
Widowed
Separated
Divorced
Language:
Children:
How did you get familiar with me? If online, what words have you searched?
Education
No schooling completed
Some high school or diploma
High school graduate
Professional/ vocational/Technical training
Bachelor's degree
Master's degree
Doctorate degree
Occupation
Employed
Unemployed, but looking for a job
Self-employed
Out of work, but looking for a job
Student
Home maker
Military
Retired
Unable to work
What kind of job do you have?
If not employed, how long has it been since the last time you worked?
What kind of job did you have?
If you quit your job, what caused you to stop working?
What are your hobbies?
Describe your current issue:
Chief complaint:
Present illness:
Specific question/intervention:
Current symptoms/stressors:
Duration of symptoms:
If you have any particular personal, or family issue that require attention, please explain in detail.
Predisposing factors
Precipitating factors
Perpetuating factors
Personal History
At what age you used drug/s for the 1st time?
Do you remember why did you start using drugs?
Why do you think you get stuck in it?
What were the harmful effects of using substance (addictive behavior) on your life?
Individual
Family
Social
Economical
Communicational
Health
Romantic relationship
Violence/crime records:
Self- harm
Risky Behavior
Detain/ arrest
To be in custody
Domestic dispute
Criminal record
Speeding ticket
Street crime
Jail/prison
Prison sentence
Aggressive behaviors
Addiction History
Do you smoke cigarette?
At what age did you start smoking?
How many years did you smoke in total?
How many cigarettes per day?
Are you Light, Moderate, or Heavy Smoker? 1-10 cigarette per day: light smoker 11-19 cigarettes per day: Moderate smoker 2O cigarette or more: Heavy smoker
Light smoker
Moderate smoker
Heavy smoker
Current alcohol or substance use:
How often do you have a drink containing alcohol?
Never
Particular time
Monthly or less
2 to 4 times a month
2 to 3 times a week
4 or more times a week
every day
How many units of alcohol do you drink on a typical day when you are drinking? *A drink-Beer: 341 ml/ (12 oz.)/ 5%-Wine: 142 ml (5 oz.)/ 12%-Distilled/spirit/alcohol/ liquor; Brandy, Rum, Whisky, Arrack; 43ml (1.5 oz.) 40%
1 or 2 drinks
3 or 4 drinks
5 or 6 drinks
7 to 9 drinks
10 or more drinks
Heavy user Men more than 14 drink per week/ 4drink per day /Women more than 7drink per week/ more than 3 drink per day 5 or more days in the past 30 days!
Moderate 1 drink per day for women / up to 2 drinks per day for men.
Binge Drinking/ Alcoholic Woman consumes 4 drinks in a 2-hour time frame/ man consumes 5 drinks in a 2-hour time frame at least 1 day in the past 30 days!
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Past attempts to quit/ what kind of format of treatment did you get? previous results?
Do you have a history of addiction treatment? How many times? When? Where? What kind of treatment? What was the results?
Have you ever been treated or diagnosis with alcoholism, drug addiction or addictive behavior?
Alcoholism
Drug Addiction
Addictive behavior
Eating disorder
Sex Addiction
Pornography/ Porn Addiction
Internet Addiction
Video game
Which of the following drugs do you use?
Ecstasy
Sleeping pills
Weeds/ Marijuana
Hashish
crack
Morphine
Naas
LSD
Heroin
Cocaine
Opium
Psychological medication
Opium extract
Shisheh
Which type of drug administration do you use?
Sniff (via nose)
Smoke (like cigarette)
Oral
Injection
How often do you use the drug/drugs?
once per day
several time a day
once a week
several times a week
How much drug do you use every time?
Do you have any specific plan to use, or its whenever you want?
What physical or psychological changes occur after drug use?
Do you have any experience of overdose?
Do you have any experience of overdose?
In what occasions do you use drugs?
Physical and Psychiatrist History
Past Physical/ Psychiatric/ Surgical History
Medical Hospitalizations:
Medical Hospitalizations:
Reason/s of hospitalization
Allergies:
Food
Drug
Insect
Substance
Other
Have you previously received and type of mental health services (psychotherapy, psychiatric, etc.?
What was the result? The method they applied?
Are you currently taking any prescription medication?
If yes, please list:
Family History
Does your one of your family member (father, mother, sisters or brothers) use special substance, alcohol or drugs? What about family members’ mental health issues?
Treatment plan
Problem selection/list:
Problem definition:
Goal development:
Objective construction:
Intervention creation:
Diagnostic determination:
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