• Pre-fill Comprehensive Assessment Questionnaire

• Please answer this questionnaire prior to meeting with counselor

• Client's Name*
  First NameMiddle NameLast Name
• Date of Birth*
   -Month -DayYear

  Date
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• Please let us know if we can help you with interpreting, assistance with technology or with written materials. Can we help with anything?
  YesNo
• What types of accommodations can we help you with?
• Have you had a Rule 25 or Comprehensive Assessment in the last 45 days?
  YesNo
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• Current Address*
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
• Phone Number*
  Please enter a valid phone number.
• Email*
  example@example.com
• Gender*
• Insurance Provider*
• PMI or Member ID*
• Last 4 of SSN*
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• Primary Language
• What race do you consider yourself to be?
  Black or African AmericanEast African/Somali/African-bornAsianNative Hawaiian or Pacific IslanderAlaska NativeWhiteNative AmericanOther
• Are you Hispanic
  YesNo
• Tribe Enrollment?
  YesNo
• How would you identify your sexuality as?
  Heterosexual (straight)HomosexualAsexualBisexualOther
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• The following questions are about the common psychological, behavioral, personal problems. These problems are considered significant when you have them for two or more week, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can't go on. After each of the following questions, please tell us the last time, if ever, you had the problem by answering whether it was in the past month, 2 to 3 months ago, 4 to 12 months ago, 1 or more years ago, or never.

• 1. IDScr: When was the last time that you had significant problems with...

• a. Feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• b. Sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• c. Feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• d. Becoming very distressed and upset when something reminded you of the past?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• f. Seeing or hearing things that no one else could see or hear or feeling that someone else could read or control your thoughts?*
  Past month2-3 months ago4-12 months ago1+ years agoNever

• When was the last time that you did the following things two or more times?

• a. Lied or conned to get things you wanted or to avoid having to do something*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• b. Had a hard time paying attention at school, work, or home*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• c. Had a hard time listening to instructions at school, work, or home*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• d. Had a hard time waiting for your turn*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• e. Were a bully or threatened other people*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• f. Started physical fights with other people*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• g. Tried to win back your gambling losses by going back another day*
  Past month2-3 months ago4-12 months ago1+ years agoNever

• When was the last time that...

• a. You used alcohol or other drugs weekly or more often?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• b. You spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or recovering from the effects of alcohol or other drugs(e.g., feeling sick)?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• c. You kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• d. Your use of alcohol or other drugs caused you to give up or reduce your involvement in activities at work, school, home, or social events?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• e. You had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or you used any alcohol or other drugs to stop being sick or avoid withdrawal problems?*
  Past month2-3 months ago4-12 months ago1+ years agoNever

• When was the last time that you...

• a. Had a disagreement in which you pushed, grabbed, or shoved someone?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• b. Took something from a store without paying for it?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• c. Sold, distributed, or helped to make illegal drugs?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• d. Drove a vehicle while under the influence of alcohol or illegal drugs?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• e. Purposely damaged or destroyed property that did not belong to you?*
  Past month2-3 months ago4-12 months ago1+ years agoNever
• How many minutes to complete this survey
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• Please select all the reasons you are looking for help today?
  Requirement of Recovery Community Organization or to continue PRSSLegal issue related to my substance useMy friends or family told me I needed helpI lost my job or had other consequences or recommendation from workI have been required to attend treatmentI realized I need help on my ownNot sure if I need treatment but I agreed to complete the assessmentOther
• How often do you use more than you planned on?
  Almost all dayLots of time (more than once a week)Sometimes (once a week or less)Almost never
• In what ways have you tried to control, cut-down or quit your use?
  Limiting days or times that I useSwitching substancesOnly using in certain locationsOnly using with certain peopleChanging method of use (snorting instead of injecting)Other
• About how much time do you spend getting, using or getting over using alcohol or drugs?
  Almost all dayLots of time (more than once a week)Sometimes (once a week or less)Almost never
• Have you overdosed?
  YesNo
• Do you have access to Narcan?
  YesNo
• On a scale of 0-10, how concerned are other people about your alcohol or drug use (0 is not concerned at all, 10 is very concerned)
• On a scale of 0-10, how concerned are you about your use?
• Which Amethyst staff are you working with to complete this assessment?*
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• Please select all of the substances you have misused in your lifetime.
  AlcoholMeth/AmphetaminesOpioid or Heroin/FentanylMarijuanaCocaine/CrackBenzodiazepinesBarbiturates/Sedatives/HypnoticsHallucinogensNicotineOver-the-counterOther
• Alcohol: About how many days in the past month, or within a 30 day period during your most recent active use, have you used alcohol?
• Alcohol: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Alcohol: How do you usually consume alcohol?
  DrinkOther
• Meth/Amphetamines: About how many days in the past month, or within a 30 day period during your most recent active use, have you used meth or amphetamines?
• Meth/Amphetamines: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Meth/Amphetamines: How do you usually use meth/Amphetamine?
  Oral (ingest)Snort (nasal)SmokeIV
• Opioids or Heroin/Fentanyl: About how many days in the past month, or within a 30 day period during your most recent active use, have you used opioids?
• Opioids or Heroin/Fentanyl: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Opioids or Heroin/Fentanyl: How do you usually use Opioids?
  Oral (ingest)Snort (nasal)SmokeIV
• Marijuana: About how many days in the past month, or within a 30 day period during your most recent active use, have you used marijuana?
• Marijuana: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Marijuana: How do you usually use Marijuana?
  Oral (ingest)SmokeOther
• Cocaine/Crack: About how many days in the past month, or within a 30 day period during your most recent active use, have you used cocaine?
• Cocaine/Crack: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Cocaine/Crack: How do you usually use Cocaine/Crack?
  Oral (ingest)Snort (nasal)SmokeIV
• Benzodiazepines: About how many days in the past month, or within a 30 day period during your most recent active use, have you used Benzodiazepines?
• Benzodiazepines: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Benzodiazepines: How do you usually use benzodiazepines?
  Oral (Ingest)Snort (Nasal)Other
• Barbiturates/Sedatives/Hypnotics: About how many days in the past month, or within a 30 day period during your most recent active use, have you used Barbiturates?
• Barbiturates/Sedative/Hypnotics: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Barbiturates: How do you usually use barbiturates/sedative/hypnotics?
  Oral (ingest)IVOther
• Hallucinogens: About how many days in the past month, or within a 30 day period during your most recent active use, have you used hallucinogens?
• Hallucinogens: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Hallucinogens: How do you usually use Hallucinogens?
  Oral (ingest)SmokeOther
• Nicotine: About how many days in the past month, or within a 30 day period during your most recent active use, have you used nicotine?
• Nicotine: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Nicotine: How do you usually use Nicotine?
  Oral (ingest)Smoke (vape)Other
• Over-the-Counter: About how many days in the past month, or within a 30 day period during your most recent active use, have you used Over-the-counter medications?
• Over-the-counter: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Over-the-counter: How do you usually use Over-the-counter?
  Oral (ingest)Nasal (snort)SmokeIVOther
• Other: About how many days in the past month, or within a 30 day period during your most recent active use, have you used other substances?
• Other: Last date of use? Please estimate if unsure
   -Month -DayYear

  Date
• Other substances: How do you usually use Other substances?
  Oral (ingest)Snort (Nasal)SmokeIVOther
• In the past 30 days, have you had any of the following withdrawal symptoms?
  SweatingShaky/jittery/tremorsUnable to sleepAgitationHeadacheFatigue/extremely tiredSad/depressed feelingMuscle AchesVivid/unpleasant dreamsIrritabilitySensitivity to noiseHigh blood pressuresOtherNausea/vomitingDizzinessSeizuresDiarrheaDiminished appetiteHallucinationsFeverUnable to eatPsychosisConfused/Disrupted SpeechAnxiety/WorriedNone
• If you stopped using, what symptoms do you think you might have?
  SweatingShaky/jittery/tremorsUnable to sleepAgitationHeadacheFatigue/extremely tiredSad/depressed feelingMuscle AchesVivid/unpleasant dreamsIrritabilitySensitivity to noiseHigh blood pressuresOtherNausea/vomitingDizzinessSeizuresDiarrheaDiminished appetiteHallucinationsFeverUnable to eatPsychosisConfused/Disrupted SpeechAnxiety/WorriedNone
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• How many times have you been to each of the following?

  Please estimate if you are unsure.
• Inpatient psychiatric unit
• Detox Center/Unit
• Residential/ Inpatient Treatment
• Outpatient Treatment
• Individual therapy/counseling
• Mutual aid meetings (12 step groups, SMART Recovery, etc.)
• Have you ever been told or have you ever thought you had any mental health conditions? If so, what have been your historic diagnoses?
• What mental health issues (if any) are you currently experiencing?
• Are you currently under the care of a mental health provider?
• Have you received prior treatment for mental health?
• Do any members of your family struggle with their mental health? If so, please tell us who and with what they have struggled with.
• Are you currently prescribed any medications for mental health issues?
• Are you a veteran?
  YesNo
• Have you ever been diagnosed with a traumatic brain injury or Alzheimer's?
  YesNo
• Have you ever hit your head or been hit on the head?
  YesNo
• Were you ever seen in the Emergency room, hospital, or by a doctor because of an injury to your head?
  YesNo
• Did you ever lose consciousness or experience a period of being dazed and confused because of an injury to your head?
  YesNo
• Have you had any significant illness that affected your brain (brain tumor, meningitis, West Nile Virus, Covid-19 or Coronavirus, stroke or seizure, heart attack, near drowning or near suffocation?
  YesNo
• Do you experience any of these problems in your daily life since you experienced an injury to your head (select all that apply)
  HeadachesAnxietyDifficulty concentratingDifficulty reading, writing, calculatingDifficulty performing your job/school workPoor judgment (being fired from job, arrests, fights)DizzinessDepressionDifficulty rememberingPoor problem solvingChange in relationships with others
• Have you ever been diagnosed with Fetal Alcohol Effects or Fetal Alcohol Syndrome?
  YesNo
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• Do you have any specific physical needs/accommodations that would be important for us to know?
• Do you have any current health or medical concerns?
  YesNo
• Current biomedical concerns
• Do you take any medications for physical health?
• Do you have a Primary Care Provider
  YesNo
• Are you pregnant?
  YesNoNot applicable
• Are you receiving prenatal care?
  YesNoNot applicable
• Have you had any major surgeries or hospitalizations?
  YesNo
• Major surgeries or hospitalizations
• Have you had any injuries, assaults/violence towards you, accidents, health related issues, or hospitalizations related to your use of alcohol or other drugs?
• What other medical or health related issues have you had in the past?
• Do you experience any challenges or difficulties with learning?
  YesNo
• Did you ever have tutoring in Math or English?
  YesNo
• Highest level of education*
  Please Select Some high school GED High School Some College Associates Degree Bachelors Degree Graduate or Professional Degree
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• Are you blind or do you have difficulty seeing?
  YesNo
• Are you deaf or do you have serious difficulty hearing?
  YesNo
• Do you have difficulty concentrating, remembering or making decisions?
  YesNo
• Do you have difficulty walking or climbing stairs?
  YesNo
• Do you have difficulty dressing or bathing?
  YesNo
• Are you able to walk on your own without assistance?
  YesNo
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• On a scale from 0-10, how much support do you need in the following areas? 0 being no support at all and 10 being a significant amount of support in this area.

• Recovery and mental health
• Housing and shelter
• Employment and income
• Food
• Physical health
• Education
• Family, Friends, and relationships
• Transportation
• Legal needs
• Having fun
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• Our main goal is to help you find treatment and resources that would be most helpful to your recovery. Please rate the following options on a scale of 0 (not helpful at all) to 10 (extremely helpful).

• Residential treatment
• Outpatient treatment
• Individual therapy
• Housing support or finding housing
• Working individually with a peer recovery specialist
• Help finding a job
• Medical care for physical issues
• Medication for alcohol or opioid use disorder (includes Natrexone or Vivitrol, Suboxone or buprenorphine, methadone)
• Support with education or going back to school
• 12 Step resources
• Non-12 Step resources
• Legal supports
• Harm reduction services
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• Are you currently in a significant relationship?
  YesNo
• Marital status
  Not MarriedMarriedDivorcedWidowed
• What is your current living situation?*
  In supportive or recovery housingStaying with family or friendsUnhoused, staying in the shelterUnhoused, staying on the streetsHouse or apartment that I rentHouse or condo that I ownOther
• Who do you live with?*
• Do they use alcohol or drugs?
  NeverRarleySometimes (once a week)Often (more than once week)Everyday
• Are you concerned for your safety there?
  YesNo
• Are you concerned about the safety of anyone else who lives with you?
  YesNo
• Do you have dependent minor children who live with you?
  YesNo
• Do you have dependent minor children who do not live with you?
  YesNo
• Do you feel supported in your recovery efforts? In other words, do you feel like you have the necessary supports in place to attend treatment?
  YesNo
• Who do you feel supported by? (Check all that apply)
  Partner/spouseSiblings/cousinsChildren's father/motherCommunity of faith membersOtherChildrenFriends/neighborsSupport group membersSocial worker/counselor/therapist/healer
• Do you want to include any of these people in your treatment process? If so, who? Please be specific.
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• Are you currently engaged with probation, parole, diversion courts or have other justice involved issues?
  YesNo
• Please explain any legal problems including any outstanding warrants, commitments, or CPS involvement
• Are there any obstacles to participating in treatment? (Time off work, childcare, funding, transportation, pending jail time, living situation, etc.)
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