Pre-fill Comprehensive Assessment Questionnaire

  • Pre-fill Comprehensive Assessment Questionnaire

  • Please answer this questionnaire prior to meeting with counselor

  • Date of Birth*
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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?
  • Have you had a Rule 25 or Comprehensive Assessment in the last 45 days?
  • Format: (000) 000-0000.
  • What race do you consider yourself to be?
  • Are you Hispanic
  • Tribe Enrollment?
  • How would you identify your sexuality as?

  • 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?*
  • b. Sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?*
  • c. Feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen?*
  • d. Becoming very distressed and upset when something reminded you of the past?*
  • f. Seeing or hearing things that no one else could see or hear or feeling that someone else could read or control your thoughts?*

  • 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*
  • b. Had a hard time paying attention at school, work, or home*
  • c. Had a hard time listening to instructions at school, work, or home*
  • d. Had a hard time waiting for your turn*
  • e. Were a bully or threatened other people*
  • f. Started physical fights with other people*
  • g. Tried to win back your gambling losses by going back another day*

  • When was the last time that...

  • a. You used alcohol or other drugs weekly or more often?*
  • 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)?*
  • 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?*
  • 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?*
  • 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?*

  • When was the last time that you...

  • a. Had a disagreement in which you pushed, grabbed, or shoved someone?*
  • b. Took something from a store without paying for it?*
  • c. Sold, distributed, or helped to make illegal drugs?*
  • d. Drove a vehicle while under the influence of alcohol or illegal drugs?*
  • e. Purposely damaged or destroyed property that did not belong to you?*
  • Please select all the reasons you are looking for help today?
  • How often do you use more than you planned on?
  • In what ways have you tried to control, cut-down or quit your use?
  • About how much time do you spend getting, using or getting over using alcohol or drugs?
  • Have you overdosed?
  • Do you have access to Narcan?
  • Please select all of the substances you have misused in your lifetime.
  • Alcohol: Last date of use? Please estimate if unsure
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  • Alcohol: How do you usually consume alcohol?
  • Meth/Amphetamines: Last date of use? Please estimate if unsure
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  • Meth/Amphetamines: How do you usually use meth/Amphetamine?
  • Opioids or Heroin/Fentanyl: Last date of use? Please estimate if unsure
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  • Opioids or Heroin/Fentanyl: How do you usually use Opioids?
  • Marijuana: Last date of use? Please estimate if unsure
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  • Marijuana: How do you usually use Marijuana?
  • Cocaine/Crack: Last date of use? Please estimate if unsure
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  • Cocaine/Crack: How do you usually use Cocaine/Crack?
  • Benzodiazepines: Last date of use? Please estimate if unsure
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  • Benzodiazepines: How do you usually use benzodiazepines?
  • Barbiturates/Sedative/Hypnotics: Last date of use? Please estimate if unsure
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  • Barbiturates: How do you usually use barbiturates/sedative/hypnotics?
  • Hallucinogens: Last date of use? Please estimate if unsure
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  • Hallucinogens: How do you usually use Hallucinogens?
  • Nicotine: Last date of use? Please estimate if unsure
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  • Nicotine: How do you usually use Nicotine?
  • Over-the-counter: Last date of use? Please estimate if unsure
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  • Over-the-counter: How do you usually use Over-the-counter?
  • Other: Last date of use? Please estimate if unsure
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  • Other substances: How do you usually use Other substances?
  • In the past 30 days, have you had any of the following withdrawal symptoms?
  • If you stopped using, what symptoms do you think you might have?

  • How many times have you been to each of the following?

    Please estimate if you are unsure.
  • Are you a veteran?
  • Have you ever been diagnosed with a traumatic brain injury or Alzheimer's?
  • Have you ever hit your head or been hit on the head?
  • Were you ever seen in the Emergency room, hospital, or by a doctor because of an injury to your head?
  • Did you ever lose consciousness or experience a period of being dazed and confused because of an injury to your head?
  • 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?
  • Do you experience any of these problems in your daily life since you experienced an injury to your head (select all that apply)
  • Have you ever been diagnosed with Fetal Alcohol Effects or Fetal Alcohol Syndrome?
  • Do you have any current health or medical concerns?
  • Do you have a Primary Care Provider
  • Are you pregnant?
  • Are you receiving prenatal care?
  • Have you had any major surgeries or hospitalizations?
  • Do you experience any challenges or difficulties with learning?
  • Did you ever have tutoring in Math or English?
  • Are you blind or do you have difficulty seeing?
  • Are you deaf or do you have serious difficulty hearing?
  • Do you have difficulty concentrating, remembering or making decisions?
  • Do you have difficulty walking or climbing stairs?
  • Do you have difficulty dressing or bathing?
  • Are you able to walk on your own without assistance?

  • 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.

  • 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).

  • Are you currently in a significant relationship?
  • Marital status
  • What is your current living situation?*
  • Do they use alcohol or drugs?
  • Are you concerned for your safety there?
  • Are you concerned about the safety of anyone else who lives with you?
  • Do you have dependent minor children who live with you?
  • Do you have dependent minor children who do not live with you?
  • 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?
  • Who do you feel supported by? (Check all that apply)
  • Are you currently engaged with probation, parole, diversion courts or have other justice involved issues?
  • Should be Empty: