PLEASE NOTE, you will need the following to complete this form

• Name, address and phone number of your probation officer, parole officer, judge or diversion officer.
• A copy of your probation, parole, court or diversion order, including treatment requirements must be included.

Your Contact Information

Demographics

Questions 1-11 relate to facts about alcohol, other drugs and driving. Please mark only one answer per row.

Questions 12-20 relate to drinking and driving attitudes and behavior. People feel differently, so there are no “right” or “wrong” answers.

© 2010 The Change Companies®

Primary Drug of Choice

Secondary Drug of Choice

Tertiary Drug of Choice

In the six (6) months prior to admission, how many times did you...

The following questions must be answered by all clients seeking admission to this program for any education or treatment; as required by Colorado law. Refusal to cooperate, or failure to provide complete or accurate information, including failure to sign a release of information to the referring criminal justice agency, will result in a denial to attend the treatment program and notification of authorities, in accord with the requirements in C.R.S. 17-27.1-101.

Upload a copy of your probation, parole, court, or diversion order that includes your court-mandated requirements.

If you do not have this document you will be required to provide at the time of your intake.

Form C

Interstate Compact Unit
940 N Broadway
Denver, CO 80203
P 303.763.2408 F 303.861.1548
DOC_interstatetreatment.state.co.us

Jared Polis, Governor | Dean Williams, Executive Director

INFECTIOUS DISEASE MEDICAL AND BEHAVIORAL SCREENING

In response to increasing rates of hepatitis B and C, sexually transmitted diseases, TB and HIV, all clients/patients receiving services from substance abuse treatment providers licensed by theAlcohol and Drug Abuse Division (ADAD) shall be screened for past and present risk factors, including those associated with substance abuse, for disease acquisition and transmission. In a joint effort, ADAD, the Colorado Department of Public Health and Environment, substance abuse treatment providers and HIV and hepatitis advocacy groups and coalitions have developed twoScreens for determining client/patient risk. In introducing the Screens to clients/patients the following points should be made (not in preferential order):Administering a screen is required by state regulation;

• Privacy of responses to screen questions is protected by federal regulation and state law;
• The screen provides important information to clients/patients about their levels of risk;
• In order to get the best information, honest, accurate responses to questions are vital.

INFECTIOUS DISEASE BEHAVIORAL SCREEN

The Infectious Disease Behavioral Screen can be self-administered or used in a face-to-face interview. The questions identify behaviors that may place clients/patients at risk for HIV and hepatitis B and C exposure. A scoring instrument for the screen tallies numeric values of client/patient responses and indicates appropriate clinical responses.

Because of the sensitive nature of the information being collected and the possibility of clients/patients perceptions of personal intrusion, it is recommended that the Screen be administered after some rapport and trust has been established, preferably following HIV and hepatitis education. If self-administered, a counselor or other person knowledgeable about the Screen should be available to assist with any client/patient questions or concerns.

I understand that my responses to this screen are protected under the federal regulations governing Confidentiality

Of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that HIV, STD and TB related information about me is protected by state law and cannot be disclosed unless state law authorizes the disclosure.

I have read and understand the above.

SCORE OVER 120 = HIGH RISK

A score over 120 indicates you are at high risk for acquiring/transmitting HIV and/or Hepatitis. See your counselor right away for referral to your local county health department or the Colorado Department of Public Health and Environment for further evaluation and follow-up.

 

SCORE BETWEEN 30-119 = MEDIUM RISK

A score of 30-119 indicates that you are at medium risk for acquiring/transmitting HIV and/or Hepatitis.

See your counselor for more information about ways that you can reduce your risk and other programs that can help you.

 

SCORE BELOW 29 = LOW RISK

A score of 0-29 indicates that you are at low risk for acquiring HIV and/or Hepatitis. Low risk doesn’t necessarily mean no risk. See your counselor if you have questions or concerns about behaviors that may place a person at risk.

YOUR COUNSELOR IS REFERRING YOU TO THE FOLLOWING AGENCY / PROGRAM FOR

FOLLOW-UP:

Community Health Services (Pitkin County)

405 Castle Creek Road, Suite 6 1

Aspen, CO 81611 

970-920-5420

 

Public Health-Rifle

95 West 14th Street

Rifle, CO 81650

970-625-5200

 

Public Health – Glenwood Springs 

2014 Blake Avenue

Glenwood Springs, CO 81601 

970-645-6614

 

Clear Creek County Public Health

1531 Colorado Blvd. (Comm. Res. Ctr)

Idaho Springs, CO 80452

303-567-3147

 

Eagle County Public Health 

100 W. Beaver Creek Blvd. 

Avon, CO 81620

970-949-7026

 

Eagle County

20 Eagle County Road, Suite E

El Jebel, CO 81623

970-704-2760

CRISIS LINES:

AIDS hotline…………………..1-800-342-2437

Suicide hotlines………………1-800-784-2433, 1-800-SUICIDE, 1-800-273-8255

 

SUPPORT GROUPS:

Alcoholics Anonymous……...(970) 928-0499

Al-anon/Alateen…………………1-888-966-4662

Narcotics Anonymous……….1-800-912-4597

INFECTIOUS DISEASE MEDICAL AND BEHAVIORAL SCREENING

In response to increasing rates of hepatitis B and C, sexually transmitted diseases, TB and HIV, all clients/patients receiving services from substance abuse treatment providers licensed by theAlcohol and Drug Abuse Division (ADAD) shall be screened for past and present risk factors, including those associated with substance abuse, for disease acquisition and transmission. In a joint effort, ADAD, the Colorado Department of Public Health and Environment, substance abuse treatment providers and HIV and hepatitis advocacy groups and coalitions have developed twoScreens for determining client/patient risk. In introducing the Screens to clients/patients the following points should be made (not in preferential order):Administering a screen is required by state regulation;

• Privacy of responses to screen questions is protected by federal regulation and state law;
• The screen provides important information to clients/patients about their levels of risk;
• In order to get the best information, honest, accurate responses to questions are vital.

INFECTIOUS DISEASE MEDICAL SCREEN

The Infectious Disease Medical Screen is intended to be self-administered at time of intake or shortly thereafter. A counselor or other person knowledgeable about the Screen should be available to assist with any client/patient questions or concerns.

Questions 1 through 8 screens for risk of hepatitis B and/or C exposure. Questions 9 through 14 screens for risk of tuberculosis exposure/infection.

Appropriate Clinical Responses Guide

A “Yes” response to any of questions 1 through 7 and no record of being tested for hepatitis B and C should prompt a referral for testing and appropriate follow-up.

A “Yes” response to question 8 should prompt making information available about the possible (though low-level) risks involved.

If any of the categories in question 9 are marked, a TB skin test should be encouraged.

A “Yes” response to any of questions 10 through 14 indicates a high risk for active TB or TB infection and a referral to a healthcare practitioner or health department for testing/treatment should be made immediately.

I understand that my responses to this screen are protected under the federal regulations governing Confidentiality

Of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that HIV, STD and TB related information about me is protected by state law and cannot be disclosed unless state law authorizes the disclosure.

I have read and understand the above.

Response Guide

* If you answered “yes” to any question # 1-7, please see your counselor for a referral to be screened for hepatitis B and C.

* If you answered “yes” to question # 8, please see your counselor for a referral for infectious disease screening and testing.

* If you answered “yes” to any of the categories in question # 9, please see your counselor for a referral to be screened for TB.

* If you answered “yes” to any question # 10-14, please see your counselor immediately for a referral TB screen and treatment