Northeastern Professional Counseling

Substance Abuse Clinical Interview

Date:

Name: (First, Middle, Last)Gender: Age: DOB: Soc #:

Address City State: Zip code: Home Phone: Cell:

May we leave aVM? YES NOEmail address: (email is non-secure)

Place of Birth: Ethnic/Cultural Background: Religion:

Native Language: Marital Status: Education (highest degree/grade/level):

Occupation: Annual Income: Employer: Do you have insurance? Yes No

If YES, what type of insurance do you have? Emergency Contact: Relationship:

Phone: Referred by: May we thank this referral? Yes No

  • I live in: Apartment House Condo/Townhouse Mobile Home Rooming House Other

Person(s) Living in your home / AGE / Significant Issues
Parents / AGE / Significant Issues
Siblings / AGE / Significant Issues
  • What makes you feel good about yourself at the end of a day:
  • What weighs on your mind a lot:
  • What do you do to relax or rejuvenate:
  • What short or long term goals might you have:

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Northeastern Professional Counseling

Substance Abuse Clinical Interview

Appearance

Physically unkempt, unclean

Clothing disheveled, dirty

Clothing atypical, unusual, bizarre

Unusual physical characteristics

Behavior

*Posture

Slumped

Rigid, tense

Atypical, inappropriate

*Facial Expression

Anxiety, fear, apprehension

Depression, sadness

Anger, hostility

Decreased variability of expression

Bizarreness, inappropriateness

General Body Movements

Accelerated, increased speed

Decreased, slowed

Atypical, peculiar, inappropriate

Restless, fidgety

Amplitude and Quality of

Speech

Increased, loud

Decreased, slowed

Atypical quality, slurring, stammer

Clinician-Patient Relationship

Domineering

Submissive, overly compliant

Provocative

Suspicious

Uncooperative

Intellectual Functioning

Impaired level of consciousness

Impaired attention span

Impaired abstract thinking

Impaired calculation ability

Impaired intelligence

Orientation

Disoriented to person

Disoriented to place

Disoriented to time

Insight

Difficulty in acknowledging the presence of psychological problems

Mostly blames others or circumstances for problems

Judgment

Impaired ability to manage daily living activities

Impaired ability to make reasonable life decisions

Memory

Impaired immediate recall

Impaired recent memory

Impaired remote memory

Danger to Self or Others

Suicidal Ideation

Suicidal Intent

Suicidal Plan

Homicidal Ideation

Homicidal Intent

Homicidal Plan

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Northeastern Professional Counseling

Substance Abuse Clinical Interview

1

Northeastern Professional Counseling

Clinical Interview

  • Are you currently being treated by a counselor, psychologist, or psychiatrist? Yes No If YES:

Date(s) Name of ProfessionalTreatment Type (counseling, therapy, medication, etc.)

  • Please provide information regarding previous treatment you have received from a counselor, psychologist, psychiatrist, or other medical or mental health professional for this or other problems:

Date(s) Name of Professional Treatment TypeWhy treatment ended

  • Have you ever been hospitalized for treatment of an emotional or mental disorder? Yes No If YES:

Date(s) Name of Hospital or FacilityReason for Hospitalization

  • Please complete the information below regarding past and currentmedical conditions and treatment:

Date(s) DoctorCondition Results

  • Please list all current prescription and over the counter medication use:

Beginning (date) MedicationDoseFrequency of useCondition Treated

Any Additional Relevant Medical History:

Any current or previous use of alcohol/drugs/tobacco products:

Type of Substance Used: / Started using regularly / Route of use: Oral/inhale/smoke/inject / Frequency of use:
Per day/week/mnth / Average amount of use: example: # beers/hits / Last use:
Marijuana/hash
Alcohol (beer, wine, liquor)
Inhalants (gas, glue, Rush)
Stimulants (speed, crystal meth, uppers, crank)
Cocaine (power, crack)
Hallucinogens (LSD, Peyote, mushrooms, PCP, Ecstasy, ketamine)
Narcotics (heroin, Oxycontin, Vicodin, morphine)
Tobacco (cigarettes, smokeless, tobacco)
Others (which ones)

Evaluation of Behavioral/Consequences/Physical Symptoms indicating Abuse/Dependence:

Not Present / Slight or Occasional / Marked or Repeated
1. more used over time to achieve a desired effect (tolerance)
2. legal problems (arrests, assault, possession, dealing, paraphernalia)
3. home and family problems (loss of child to DSS, spouse left, arguing with children)
4. work or school problems (loss of job, failing school, conflict at work)
5. use against medical advice
6. guilt or depression about use
7. pre-occupation with use (can’t stop thinking about your next drink/hit)
8. loss of memory while using (blackouts)
9. financial problems related to use (using bill money or savings for alcohol/drugs)
10. change in activities and friends (using in the morning, avoiding sober friends, defensive with family)
11. attempts to cut down on use (saying you’ll “only use/drink on the weekends”)
12. general loss of control of use (find yourself using when you didn’t want or intend to)
13. Other:

History of detoxification and/or SA treatment and response:

Sweats Yes No │Hangovers Yes No │Nausea Yes No │Insomnia Yes No │Hallucinations Yes No │

Seizures Yes No │Shakes Yes No │Irritability Yes No │TremorsYes No │Other: Yes No

Have you ever been arrested for a DWI? Yes No If yes, see below:

Year BAC County/State Outcome (pre-trial/post-trial/convicted/not convicted)

Have you ever been arrested for any other legal charges related to alcohol or drugs: Yes No│If yes, describe:

Any current legal charges besides your DWI?Yes No │If yes, describe:

If there was a time you chose to stop drinking, how long did you go without drinking alcohol or using drugs?

When did this occur? Why did you abstain?

Have you ever been admitted to a substance abuse program? YesNo Not ApplicableWhere? What was the outcome?

Do you, or have you ever, attended AA/NA or other alcohol/drug self-help program regularly? Yes No Not Applicable

Have you ever been required to attend ADETS or alcohol or drug education classes? Yes No Not Applicable

Why? When? Completed? Yes No

If not currently using substances, what is being done to support abstinence?

If you wanted to be abstinent, is there anyone in your life that would support you?? Yes No If so, who?

Is there a history of alcohol or drug problems in your family? Yes No If yes, who?

If you attend treatment and find that some of your alcohol or drug choices are unhealthy, would you be willing to change some things? Yes No Additional Comments:

Axis / Type / Code / Diagnosis
I

ASAM DIMENSIONS SEVERITY OF ILLNESS DIAGNOSIS

N/A / LOW / MEDIUM / HIGH
Dimension I:
Acute Intoxication/withdrawal potential
Dimension II:
Biomedical Conditions and Complications
Dimension III:
Emotional/Behavioral or Cognitive Conditions and complications
Dimension IV:
Readiness to Change
Dimension V:
Relapse/Continued Use Potential
Dimension VI:
Recovery Environment

ASAM Recommendation: Level 0.5: Early Intervention Level I: Outpatient Services

Level II: Intensive Outpatient/Partial Hospitalization Services Level III: Residential/Inpatient Services

Level IV: Medically Managed Intensive Inpatient Services

Recommended Level of Care: (YOU MUST BEGIN YOUR TREATMENT WITHIN 6 MONTHS OF THE DATE OF THIS ASSESSMENT)

ADETS: # Hours:

Short Term: # Hours:

Long Term: # Hours:

IOP/90 hour

Inpatient Residential

Other/Special:

Licensed Counselor: ______Date:

Anna L. Coker, MA, LPC, LCAS

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