CRS Intake Pre-appointment
Demographics
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Today's Date
-
Month
-
Day
Year
Date
Phone Number
Email
example@example.com
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Substance Abuse History
Substance Abuse History
Age of Onset
Method of Use
How often
Date of last use
Avg. 24 hour use amount
Alcohol
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Cocaine
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Marijuana
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Heroin
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Other Opiates
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Hallucinogens
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Methamphetamines / Amphetamines
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Stimulants
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Benzodiazepines
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Inhalants
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
K2 / Synthetic Cannabis
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Tobacco / Smoking
Do you smoke or use tobacco?
Yes
No
For how many years have you used tobacco products?
Type of Tobacco Use
Light Cigarette Smoker (1-9 per day)
Moderate Cigarette Smoker (10-19 per day)
Heavy Cigarette Smoker (20-39 per day)
Very Heavy Cigarette Smoker (40+ per day)
Chewing Tobacco / Smokeless Tobacco
Nicotine Pouches
Vape/E-Cigarette
Other
On a Scale of 1 to 10, How Ready Are You to Quit Tobacco (Circle Below):
Worst
1
2
3
4
5
6
7
8
9
Very Ready
10
1 is Worst, 10 is Very Ready
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Health History
Gender
Male
Female
Other
Health Problems
Now
Past
Never
Comments?
Anemia
Arthritis
Bleeding Disorder
Blood Pressure
Bone/Joint Problem
Cancer
Diabetes
Epilepsy/Seizures
Eye Disease
Glaucoma
Fibromyalgia
Muscle
Headaches
Head Injury
Brain Tumor
Hearing Problems
Heart/Cardiac Disease
Hepatitis
Kidney Disease
Liver Problems
Lung Disease
Menstrual Pain
Oral/Dental Health
Stomach Issues
Seizures
Stroke
Thyroid
Infectious Diseases
Tuberculosis
AIDS/HIV
STI/STD
Learning Problems
Speech Problems
Anxiety
Bipolar
Depression
Eating Disorder
Hyperactivity/ADD
Schizophrenia
Sexual Problems
Sleep Disorder
Suicide Attempts
Suicide Thoughts
Psychiatric / Mental Health Conditions
Yes
Comments?
Anxiety
Bipolar
Depression
Eating Disorder
Hyperactivity/ADD
Obsessive Compulsive Disorder
PTSD/Trauma
Schizophrenia
Sleep Disorder
Suicide Attempts
Suicide Thoughts
Current Medications
Dose/Strength
Frequency
Comments
Med 1
Med 2
Med 3
Med 4
Med 5
Med 6
Med 7
Med 8
Additional Medications
Any known allergies?
Yes
No
Please specify allergies:
Past Surgical Procedures/Serious Injuries
Operation / Hospitalization
Year
Comments
1
2
3
4
Additional
Primary Care Physician
Do you have a PCP?
Yes
No
PCP Name
First Name
Last Name
Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Are you currently pregnant?
Yes
No
How far along?
History of Pregnancy?
Yes
No
Number of Pregnancies
Number of full-term pregnancies
Have you given birth in the last 60 days?
Yes
No
Last post-partum visit with Ob/gyn:
-
Month
-
Day
Year
Date
Pain Screening
Does pain currently interefere with your activities?
Yes
No
How much does it interefee with these activities?
Not at all
Mildly
Moderately
Sevely
Extremely
Please indicate source of the pain.
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PHQ-9, Trauma History Questionnaire
PHQ-9: Over the past 2 weeks, how often have you been bothered by any of the following problems?
0. Not at all
1. Several Days
2. More than half the days
3. Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat Difficult
Very Difficult
Extremely Difficult
Trauma History Questionnaire
The Following is a series of questions about serious or traumatic life events. Knowing about the occurrence of such events, and reactions to them will help us to develop programs for prevention, education, and other services. For each event, indicate whether it happened &, if it did, the number of times & your approximate age when it happened.
General Trauma History
Yes
No
Number of times
Approximate Age
Comments
Has anyone ever tried to take something directly from you by using force or the threat of force, such as a stick-up or mugging?
Has anyone ever attempted to or succeeded in breaking into your home.
Have you ever been in any situation in which you were serious injured? (is yes, specify)
Have you ever been in any other situation in which you feared you might be killed or seriously injured? (If yes, specify)
Have you ever seen someone seriously injured or killed? (If yes, specify)
Have you ever had a serious or life-threatening illness? (If yes, specify)
Have you ever received news of a serious injury, life-threatening illness, or unexpected death of someone close to you? (If yes, specify)
Has anyone ever pressured or forced you into unwanted physical or sexual contact?
Has anyone, including family or friends, ever attacked you with a gun, knife, or other weapon?
Have you ever experienced, witnessed or been exposed to domestic violence?
Have you experienced any other extraordinarily stressful situation or traumatic event that is not covered above? (If yes, specify)
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TB/HVC/HIV Rick Assessment
HCV Screening Questions
Were you born between the years of 1945 & 1965
Yes
No
Do you currently use IV drugs?
Yes
No
Have you previously used IV drugs?
Yes
No
Have you received a clotting factor produced before 1987?
Yes
No
Have you been on hemodialysis?
Yes
No
Human Immunodeficiency Virus Screening Questions
Do you currently use IV drugs?
Yes
No
Have you previously used IV drugs?
Yes
No
Do you engage in unprotected sexual activities?
Yes
No
Do you engage in sharing needles?
Yes
No
Tuberculosis Screening Tool
Have you traveled extensively (more than 4 weeks) outside the U.S in the last five years to high TB-incidence areas (Asia, Africa, South America, Central America)?
Yes
No
Are you an immigrant from a high TB-risk foreign country (includes countries in Asia, Africa, South America, and Central America)?
Yes
No
Have you resided in any of these facilities in the past year: jails, prisons, shelters, nursing homes and other long-term care facilities such as rehabilitation centers? (If an individual was a resident of any of these facilities and tested with the past three months, they do not need to be reassessed).
Yes
No
Have you had any close contact with someone diagnosed with TB?
Yes
No
Have you been homeless within the past year?
Yes
No
Have you ever injected drugs?
Yes
No
Do you or anyone in your household currently have the following symptoms, such as a sustained cough for two or more weeks, coughing up blood, fever/chills, loss of appetite, unexplained weight loss, fatigue, night sweats?
Yes
No
Do you currently have or anticipate having any condition that would decrease your immune system? (Examples: HIV infection, organ transplant recipient, treatment with TNF-alpha antagonist (e.g. infliximab, etanercept, others), steroids (equivalent dose of Prednisone 15mg/day for one month or longer) or any other immunosuppressive medications)
Yes
No
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Recovery Capitol Assessment
12 Step/Self-help group and spirituality assessment
Previous 12-Step or community support group attendance?
Yes
No
Current 12-Step or community support group attendance?
Yes
No
Do you have a sponsor?
Yes
No
Do you have a homegroup?
Yes
No
Frequency of self-help group attendance in the past 30 days.
Please Select
01-03 times in the past month.
04-07 times in the past month.
08-15 times in the past month.
16-30 times in the past month
More than 30 times in the past month
No attndance in the past month
Belief in a higher power?
Yes
No
Currently practicing a religion
Yes
No
Other
Religious Preference
if applicable
Education, Employment, Military
Education History
College
High School Grad
GED
Other
Highest Grade Completed
History of learning difficulties
Learning Disability/Type
Special School Placement
None Reported
Other
Barriers to Learning:
Inability to Read or Write
None Reported
Other
Are you currently employed?
Yes
No
Employment Status
Full Time (35 hrs or more per week)
Part Time (under 35 hrs per week)
Unemployed
Disabled
Retired
Student
Homemaker
Living in Institution
Other
If employed, name of employer
Number of jobs in the last five years?
Are you satisfied with your job?
Yes
No
If not employed, do you desire to work?
Yes
No
Military History
Military History
Yes
No
Describe branch of service, pertinent duties, and any trauma experienced during service.
Type of discharge:
Date of discharge:
-
Month
-
Day
Year
Date
Transportation:
Do you have a valid driver's license?
Yes
No
Are you driving without a license?
Yes
No
Do you feel you would have reliable transportation to treatment?
Yes
No
Legal Status
Current Legal Status
Yes
No
Current legal status?
Charges pending
Incarcerated
Parole
Probation
Other
Involvement in Drug Court/DUI Court/JRS
Yes
No
Court Involvment
Drug Court
DUI Court
JRS
Mental Health Court
Other
Contact Name
First Name
Last Name
History of charges?
Yes
No
Specify history of charges:
Current Living Situation
Current Living Situation (Where, ages/relationships of individuals you reside with)
How long have you lived at current location?
Do you feel your current living environment is conducive of recovery?
Yes
No
Comments
Have you moved in the past year?
Yes
No
How many times
Recreatational & Self-Care
What recreational activities/hobbies are you interested in?
What do you do for fun/leisure activities?
Do you feel you have been able to manage your money/finances?
Yes
No
What are your strengths?
What are your weaknesses?
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BARC-10 Brief Assessment of Recovery Capital
Please select a number 1 through 6 that represents your level of agreement towards the following statements. Type a question
1. Strongly Disagree
2. Disagree
3. Somewhat Disagree
4. Somewhat Agree
5. Agree
6. Strongly Agree
There are more important things to me in life than using substances
In general I am happy with my life
I have enough energy to complete the tasks I set for myself
I am proud of the community I live in and feel a part of it
I get lots of support from my friends
I regard my life as challenging and fulfilling without the need for using drugs or alcohol
My living space has helped to drive my recovery journey
I take full responsibility for my actions
I am happy dealing with a range of professional people
I am making good progress on my recovery journey
Total
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Certified Recovery Services Referral
Certified Recovery Services will provide support before, during and after treatment through lived experience of the recovery process. CRS services include Guidance in the recovery process, referral for needed support services, referral for self-help recovery supports, moral support, coaching and advocacy throughout the recovery process, guidance in building healthy social relationships and leisure, recreational activities.
Select areas where you desire additional support:
Health Care Coverage (MA, Market Place)
Basic Needs (Food, clothing, shelter, transportation)
Physical Health (Medication mgmt., PCP, Dental)
Emotional/Mental Health (Psychiatry & Mental Health Referral)
Family (counseling, education, resources)
Child Care
Legal Status (referral for legal assistance)
Life Skills (cooking, cleaning, bills, shopping)
Social (develop healthy leisure activities)
Employment (job seearch, resume writing, etc.)
Recovery Coaching / Support Group Access
Treatment Referrals (access to detox/inpatient)
Peer to Peer Support
Other
Do you have any other priorities at this time that you feel would be helpful to focus on?
Submit
Should be Empty: