New Patient Pre-Eval Form JWC Logo
  • New Patient Pre-Eval Form

  • Demographics

  •  - -
  •  - -
  • Substance Abuse History

  •  
  • Previous Drug and Alcohol and/or Mental Health Treatment

  •  
  • Tobacco / Smoking

  • Health History

  •  
  •  
  •  
  •  
  • Primary Care Physician

  • Pharmacy

    Please enter your preferred pharmacy information below
  • Emergency Contact

  • PHQ-9, Trauma History Questionnaire

  •  
  • 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.
  •  
  • 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).
  •  
  • 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

  • Human Immunodeficiency Virus Screening Questions

  • Tuberculosis Screening Tool

  • Personal and Social History

  • Employment

  • Legal

  • Children/Family

  • Military

  • Education

  • 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.
  • Should be Empty: