ADMIT ASSESSMENT

Date*

Date

Name*

First NameLast Name

What substance (s) do you use? If narcotics, how do you use them ?*

What substance (s) do you want to stop using?*

Do you have family support?*

Are you married?*

Do you have children?*

Do you have a stable living situation, conducive to your recovery?*

If yes, what are your current living arrangements?*

If no, would you like help finding a stable living situation?*

Do you have pending legal issues?*

Do you have any type of criminal history?*

If yes, what type of convictions?*

Are you currently employed?*

If yes, what do you do for work?*

If no, would you like help securing a job?*

What are your biggest strengths ?*

What are your biggest weaknesses?*

Have you attempted sobriety before?*

If yes, what is the longest time you managed to stay sober?*

If yes or no, what is motivating you to try now?*

If yes, What worked for you?*

If not, Are there any particular paths to recovery that you’d like to try/explore? What are they?*

What doesn’t / didn’t work for you?If not, What are you not willing to try/explore? Why?*

What would you say are your “triggers”?*

Do you have a primary care doctor?If not, Would you like help to locate one?*

When’s the last time you had a full physical?*

Do you have any physical illnesses/diagnoses? If yes, What are they?*

Do you have a mental health provider (psychologist and/or psychiatrist)? If not, Would you like help to locate one?*

Do you have any mental health diagnoses? If yes, What are they?

Have you ever had suicidal thoughts in the past? If yes, Have you ever attempted suicide? How?

Do you currently take any medication(s)?What are they? If not, Are you supposed to be taking any medication(s)? What are they?

Do you consider yourself to be a spiritual person? If yes, What does that mean to you?

Is there anything else you’d like to add or work on that we didn’t cover?