Home of Grace Client Assessment

Home of Grace Client Assessment Revised January 2023
Date

MonthDayYear
Date
Referred By
Email Address of Referrer
DOC
Have you ever been to the Home of Grace?
When?
Name
Date of Birth

MonthDayYear
Date
Age
SS#
Address
County
City
STATE
Zip
Phone#
Alternate#
*You will have to have a negative Covid test result from the last 24 hours before your scheduled entry date into the program*
The Home of Grace is not a medical facility. Do you have any medical or dental problems that need to be addressed prior to coming to the Home of Grace?
If so, they will need to be taken care of prior to coming to the Home of Grace. If an emergency shall arise your family will need to pick you up and you will need a medical clearance before returning to the Home of Grace.
Do you have children?
Names and ages of children
Do you take blood pressure medicine?
Do you take more than one kind of blood pressure medicine?
Do you have chronic high blood pressure?
Are you a diabetic?
Are you currently on medication?
Do you take insulin?
Are you pregnant?
Have you had prenatal care?
Do you have any open wounds?
What medication are you currently taking?
Name
how long?
Name
how long?
Name
how long?
Have you had current testing for:
TB
When?
HIV
When?
Hep C
When?
Hep B
When?
Do you have current testing for All STD's?
You will need a letter from your doctor stating you are clear of all medical issues.
Have you ever been seen by a
Psychiatrist?
Psychologist?
Counselor?
How many treatment centers have you been in previously?
How many psychiatric facilities have you been in previously?
Have you ever been diagnosed with any of the following:
Bi Polar disorder
Medication prescribed
Schizophrenia
Medication prescribed
Manic Depressant
Medication prescribed
Depression
Medication prescribed
Have you ever had seizures?
Were they drug related?
Have you ever had black outs?
Were they drug related?
Have you ever heard voices?
Were they drug related?
Have you ever had hallucinations?
Were they drug related?
Have you ever attempted suicide?
When?
How many times?
How?
Were you hospitalized?
Are you currently suicidal?
Have you ever been physically abused?
By whom?
What age?
Have you ever been sexually abused?
By whom?
What age?
Identify any drugs you have ever tried:
Alcohol
Date of last use

MonthDayYear
Date
How Much
Marijuana
Date of last use

MonthDayYear
Date
How Much
Cocaine
Date of last use

MonthDayYear
Date
How Much
Crack
Date of last use

MonthDayYear
Date
How Much
Crystal Meth
Date of last use

MonthDayYear
Date
How Much
Ecstasy
Date of last use

MonthDayYear
Date
How Much
Heroin/Fentanyl
Date of last use

MonthDayYear
Date
How Much
Oxycontin
Date of last use

MonthDayYear
Date
How Much
Morphine
Date of last use

MonthDayYear
Date
How Much
Lortab
Date of last use

MonthDayYear
Date
How Much
Opana
Date of last use

MonthDayYear
Date
How Much
Xanax
Date of last use

MonthDayYear
Date
How Much
Valium
Date of last use

MonthDayYear
Date
How Much
Soma
Date of last use

MonthDayYear
Date
How Much
Ativan
Date of last use

MonthDayYear
Date
How Much
Adderall
Date of last use

MonthDayYear
Date
How Much
Methadone
Date of last use

MonthDayYear
Date
How Much
Dilaudid
Date of last use

MonthDayYear
Date
How Much
Suboxone
Date of last use

MonthDayYear
Date
How Much
Vyvanse
Date of last use

MonthDayYear
Date
How much
Spice
Date of last use

MonthDayYear
Date
How much
Percocet
Date of last use

MonthDayYear
Date
How much
ZaZa
Date of last use

MonthDayYear
Date
How much
Any Other Drug?
Answer yes or no to the following compulsive behavior questions.
Have you ever had an issue with gambling?
Have you ever had an issue with sexually acting out?
Have you ever had an issue with Anorexia?
Have you ever had an issue with Bulimia?
Have you ever had an issue with excessively spending money?
Have you ever had an issue with being a workaholic?
Have you ever had an issue with shoplifting?
Have you ever had an issue with self injury such as burning or cutting yourself?
Any other compulsive behavior?
Legal Issues: Do you have any of the following?
Warrants
Probation Officer
Drug Court Office
DHR
Up Coming Court Dates

MonthDayYear
Date
Judge's Name
Attorney's Name
Charges
Tell me how drugs and or alcohol have negatively affected your life?
Name one family member who will be supportive to your recovery:
Name
Relationship
Phone Number
Are you on disability or SSI?
Why?
How Long?
Amount?
Even though you may be court ordered, the court does not pay for your fees. How do you plan to pay your program
Program fees are $3000.00 (plus $25.00 for OTC medications) for the program due at the time of admission. We do not accept insurance of any kind.

Contact a family member or friend and have them call 251 456-7807 to make payment arrangements prior to admission.
Name and #'s of those you contacted to arrange a payment prior to admission.
Who will help you pay your program fees?
Phone Number
Total amount $3000.00
Do you state that the above facts are true and correct to the best of your knowledge and do you understand that the penalty for providing false information is grounds for dismissal from this program?
Counselor Completing Assessment
Accepted into the program:
YES
NO
Briefly explain
Should be Empty: