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

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

  • Compass and E-form

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

  •  

    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.

  • Please write down and remember your compass account e-mail and password.  You will need this infromation during your initial appointment. 

  • Substance Abuse History

  • Rows
  • History of Overdose?
  • Do you use interveousnly?

  • 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?
  • Rows

  • Primary Care Physician

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

  • Pharmacy

    Please enter your prefered pharmacy information below
  • 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

  • Client Liability Form

  • Parti 1: Insurance

  • Do you have insurance (private and/or public coverage?
  • Have you been denied insurance in the past year?

  • Part 2: Family

    List family as detemined by Federal Law/Federal Tas Return
  • Rows

  • 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.
  • Rows
  • Rows

  • 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.

  • Crisis/Relapse Prevention Plan

  • 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 make me feel worse: These are things that do nothelp me calm down or stay safe:

  • 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:

  • 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.

  • Demographics

  • What is your race or ethnicity? Select all that apply and enter additional details in the space below. Note, you may report more than one group.
  • White - Provide Details Below
  • Hispanic or Latino - Provide Details Below
  • Black or African American - Provide Details Below
  • Asian - Provide Details Below
  • Middle Eastern or North African - Provide Details Below
  • Native Hawaiian or Pacific Islander - Provide Details Below
  • What is your sex?
  • Do you speak a language other than English at home?
  • What language?
  • Have you ever served in the Armed Forces, the Reserves, National Guard or other Uniformed Services?
  • Rows

  • Social Driver of Health

  • How hard is it for you to pay for the very basics like food, housing, medical care, and heating?
  • What is your living situation today?
  • Which of the following best describes your current living situation?
  • Are you currently employed
  • What is the highest level of education you have finished?
  • In the last 3 months, have you attended a school/college, homeschool, or vocational training regularly?
  • In the last 3 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

  • Client Reported Core Outcomes

  • Please choose the option that best applies to you right now:
  • Rows
  • Which goals do you have for participating in this program?

  • Thank you for completing this baseline form

  • Should be Empty: