New Patient Pre-Eval Form JWC

  • New Patient Pre-Eval Form

  • Demographics

  • Date of Birth
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  • Today's Date
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  • Martial Status

  • Substance Abuse History

  • Rows
  • History of Overdose?

  • Previous Drug and Alcohol and/or Mental Health Treatment

  • Have you been involved in previous treatment for D&A or Mental Health services?
  • Rows
  • Have you ever attended AA/NA or Self-Help Group Meetings?
  • Do you currently attend AA/NA or Self-Help Groups?
  • Do you have a sponsor or a homegroup
  • Do you gamble or have a history of gambling?
  • Please check any of the following that apply:

  • Tobacco / Smoking

  • Do you smoke or use tobacco?
  • Type of Tobacco Use

  • Health History

  • Rows
  • Rows
  • Rows
  • Any known allergies?
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  • Primary Care Physician

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Pharmacy

    Please enter your preferred pharmacy information below
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • PHQ-9, Trauma History Questionnaire

  • Rows
  • 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?

  • 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.
  • Rows

  • Stages of Change Readiness and Treatment Eagerness Scale

    SOCRATES is an experimental instrument designed to assess readiness for change in individuals with substance use disorders. The instrument yields three factorially-derived scale scores: Recognition (Re), Ambivalence (Am), and Taking Steps (Ts).
  • Rows
  • Decile Scores Recognition Ambivalence Taking Steps
    90 Very High   19–20 39–40
    80   18 37–38
    70 High 35 17 36
    60 34 16 34–35
    50 Medium 32–33 15 33
    40 31 14 31–32
    30 Low 29–30 12–13 30
    20 27–28 9–11 26–29
    10 Very Low 7–26 4–8 8–25

  • TB/HVC/HIV Rick Assessment

  • HCV Screening Questions

  • Were you born between the years of 1945 & 1965
  • Do you currently use IV drugs?
  • Have you previously used IV drugs?
  • Have you received a clotting factor produced before 1987?
  • Have you been on hemodialysis?

  • Human Immunodeficiency Virus Screening Questions

  • Do you currently use IV drugs?
  • Have you previously used IV drugs?
  • Do you engage in unprotected sexual activities?
  • Do you engage in sharing needles?

  • 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)?
  • Are you an immigrant from a high TB-risk foreign country (includes countries in Asia, Africa, South America, and Central America)?
  • 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).
  • Have you had any close contact with someone diagnosed with TB?
  • Have you been homeless within the past year?
  • Have you ever injected drugs?
  • 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?
  • 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)

  • Personal and Social History

  • Employment

  • Are you currently Employed
  • Employment Status:

  • Legal

  • Current Legal Status:
  • Legal Status (Check all that apply)
  • Do you have history of legal charges?

  • Children/Family

  • Do you have children?

  • Military

  • Have you ever served in the military?

  • Education

  • Crisis/Relapse Prevention Plan

  • Date of birth
     - -
  • Triggers: When these things happen, I am more likely to feel unsafe or upset.
  • Thoughts/inside warning signs: These are things I may notice just before I feel unsafe or upset.
  • Outside warning signs: These are things other people may notice just before I feel unsafe or upset.
  • Things that help me stay better or feel more in control NOW: things that can help me calm down.
  • Things that help me stay better or feel more in control NOW: things that can help me calm down.

  • 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.
  • Are you interested in accessing Recovery Support Services?
  • Select areas where you desire additional support:
  • Should be Empty: