New Patient ALDA Eval Form JWC

New Patient ALDA-Eval Form

Please complete this form ONLY if you have scheduled your initial assessment or are currently engaged in treatment with JADE Wellness Center. If you have not yet scheduled your initial assessment, please do not complete this form. Instead, call 412-380-0100 to schedule your appointment.
Demographics
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Phone Number
Email
example@example.com
Address

Street Address

CityState

Zip Code
How long have you lived at current location?
Height
Input Height
Weight
Input Weight
Martial Status

SingleMarriedDivorcedWidowedSeparatedOther

Compass and E-form

Complete Compass Application Online
I have written down my compass account e-mail and password*

YesNo
Please complete the compass application by following the link below.
You will then receive your e-form number and a list of documents you must upload.

Compass Application

if you need to contact compass directly regarding your application please use the contact number below:

Compass contact number: 800-692-7462

Typical required documents (if applicable)
- Identification Card or Passport
- Bank statement (if a bank account is identified)
- Proof of Disability (if chronic condition or ongoing health care need is idetnified)
- Proof of income (if employed)
- Proof of rent/mortgage or bills (if identified)
Note: all these documents can be brought to your initial assessment and uploaded during your appointment if you need assistance.
E-form Number*
Please write down and remember your compass account e-mail and password. You will need this infromation during your initial appointment.

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

Client Liability Form
Parti 1: Insurance
County of Residency
Do you have insurance (private and/or public coverage?

YesNo
Primary Insurance Name:
Primary Insurance ID:
Secondary Insurance Name:
If Appliable
Secondary Insurance ID:
If Applicable
Have you been denied insurance in the past year?

YesNo
Reason for denial:
Part 2: Family

List family as detemined by Federal Law/Federal Tas Return

List Family as determined by Federal Law/Federal Tax Return

	Name of Dependents	Relationship
1. Self
2.
3.
4.
5.
6.
7.
8.
9.

Total number of dependents (including self)
Part 3: Monthly Gross Income

List all income from full and part-time employment as well as other types of income including that of Self, Spouse and Parents.

List entire household income - this includes everyone who is actively employeed living in your household.

	Employers	Monthly Gross Income
Self
Spouse
Parent 1 (if applicable)
Parent 2 (if applicable)
Other (household member)
Other (household Member)

Total Monthly Gross Income

Types of Income

	Self	Spouse	Parent 1	Parent 2	Other	Total
Earned Income (wages, salaries, tips, etc.)
Interest Income
Dividends
Benefits (unemployment, Social Security, Pension)
Alimony
Other taxable income
Total

Total Monthly Gross Income
Description of types of income:

Earned Income:
Wages, salaries, fees, commissions, tips, bonuses, net business income and other earned income subject to Federal income taxation.

Interest Income:
Interest income including, but not limited to, interest received from accounts with banks, savings and loan associations, money market funds, credit unions or bonds.

Dividends:
Dividends received from corporate stock holdings or cash dividends from life insurance policies.

Benefits:
Taxable benefits, including but not limited to unemployment compensation, Social Security payments and pensions. Benefits are counted as income only if the benefit is paid on behalf of the client. Food stamps are not counted as income.

Alimony:
Includes alimony received or spousal support received prior to divorce. Does not include child support.

Other taxable income:
Includes all other income subject to Federal income taxation, e.g., rental income, lottery winnings, net capital gains, etc.

SOR / GPRA PRT - C - Unified Performance Reporting Tool

ADULT / CLIENT / BASELINE / FORM
CLIENT CONSENT

Are you answering for your child as a caregiver or family member? This form was designed for adults (persons 18 years or older) responding for themselves. If that's not you, please ask your provider for the form for caregivers/family members or for youth (12-17 years old).

What is GPRA - C - form about?

The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your provider.

How is my information used?

SAMHSA does not collect your name or information that can identify you. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data.
SAMHSA combines information collected to see if services need to be improved.

Do I have to fill in this form?

No. You do not have to fill in this form. This will not result in any loss of services or benefits. If you choose to participate, you may:
*skip questions you do not want to answer.
*stop filling in the form at any time.

How long does it take to fill in the form?

*It should take you about 15 minutes.

How do I agree to participate?

By answering the following questions, you are agreeing to participate.

	Age of Onset	Method of Use	How often	Date of last use	Avg. 24 hour use amount
Alcohol
Cocaine
Marijuana
Heroin
Other Opiates
Hallucinogens
Methamphetamines / Amphetamines
Stimulants
Benzodiazepines
Inhalants
K2 / Synthetic Cannabis

	Dates	Location/Type of Service
D&A Outpatient
D&A Inpatient
MH Outpatient

	Family Member(s)	Comments
Cancer
Diabetes
Heart Disease
Hypertension
Stroke
Seizure
High Cholesterol
Addition
Psychiatric

	Now	Past	Never	Any thoughts?
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 Disease
Hepatitis
Kidney Disease
Lung Disease
Menstrual Pain
Oral/Dental Health
Stomach Issues
Stroke
Thyroid
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

	Medication	Dosage/Strength	Frequency
Med 1
Med 2
Med 3
Med 4
Med 5
Med 6
Med 7
Med 8
Additional Medications

New Patient ALDA-Eval Form

Demographics

Compass and E-form

Substance Abuse History

Previous Drug and Alcohol and/or Mental Health Treatment

Tobacco / Smoking

Health History

Primary Care Physician

Pharmacy

PHQ-9, Trauma History Questionnaire

Trauma History Questionnaire

Stages of Change Readiness and Treatment Eagerness Scale

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

Client Liability Form

Parti 1: Insurance

Part 2: Family

Part 3: Monthly Gross Income

Certified Recovery Services Referral

SOR / GPRA PRT - C - Unified Performance Reporting Tool

Demographics

Social Driver of Health

Client Reported Core Outcomes

Thank you for completing this baseline form

	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

	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)

	Disagree Strongly	Disagree	Uncertain	Agree	Agree Strongly
1. I really want to make changes in my use of substances.
2. Sometimes I wonder if I am an addict or alcoholic.
3. If I don’t change my drug/alcohol use soon, my problems are going to get worse.
4. I have already started making some changes in my use of drugs or alcohol.
5. I was using drugs or alcohol too much at one time, but I’ve managed to change that.
6. My substance use is causing problems with the law.
7. I have a problem with substances.
8. I’m not just thinking about changing my drug or alcohol use, I’m already doing something about it.
9. I have already changed my drug or alcohol use, and I am looking for ways to keep from slipping back to my old pattern.
10. I have serious problems with drugs and/or alcohol.
11. Sometimes I wonder if I am in control of my drug or alcohol use.
12. My drug or alcohol use is causing a lot of harm.
13. I am actively doing things now to cut down or stop my use of substances.
14. I want help to keep from going back to the drug or alcohol problems that I had before.
15. I know that I have a drug or alcohol problem.
16. There are times when I wonder if I use drugs or alcohol too much.
17. I am an addict or alcoholic.
18. I am working hard to change my substance use.
19. I have made some changes in my substance use, and I want some help to keep from going back to the way I used before.

	Yes	No	Prefer not to answer
Are you deaf or do you have serious difficulty hearing
Are you blind or do you have serious difficulty seeing, even when wearing glasses
Because of a physical, mental, or emotional condition, do you have a serious difficulty concentrating, remember, or making decisions
Do you have serious difficulty walking or climbing stairs
Do you have difficulty dressing or bathing
Because of physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping

	Strongly agree	Agree	Somewhat Agree	Somewhat Disagree	Disagree	Strongly Disagree	Prefer not to answer
I am physically fine most days
My mental health is fine most days
My substance use does not cause problems in my life
I have stable housing
I have a steady job or am involved in thing like school, training, or volunteering
My life has purpose and meaning
I have enough money to meet my needs
I am proud of the community I live in and feel a part of it
I am supported by the people around me
The future appears bright to me
I am in control of my life
I bounce back quickly after hard times

	Operation / Hospitalization	Year	Comments
1
2
3
4
Additional