HILL ALCOHOL AND DRUG TREATMENT COURT ASSESSMENT

HILL ALCOHOL AND DRUG TREATMENT COURT ASSESSMENT
NAME:

First NameLast Name
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN:
PHONE:
Please enter a valid phone number.Format: (000) 000-0000.
WORK PHONE:
Please enter a valid phone number.Format: (000) 000-0000.
DOB:

MonthDayYear
Date
EMPLOYER:

First NameLast Name
SPOUSE:

First NameLast Name
PHONE:
Please enter a valid phone number.Format: (000) 000-0000.
CASE #
CLIENT ATTORNEY

First NameLast Name
PHONE:
Please enter a valid phone number.Format: (000) 000-0000.
FAX:
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OPPOSING ATTORNEY:

First NameLast Name
PHONE:
Please enter a valid phone number.Format: (000) 000-0000.
FAX:
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EVENT THAT PROMPTED ASSESSMENT:
REFERRING ENTITY:

First NameLast Name
CAREER
Have you ever been disciplined or counseled at work for:
A. Absenteeism?

YN
B. Tardiness?

YN
C. Intoxication?

YN
D. Theft?

YN
E. Positive urinalysis?

YN
F. Other?

YN
PLEASE DESCRIBE:
FINANCIAL
A. Have you ever spent money on alcohol or drug use?

YN
B. Have you ever declared bankruptcy?

YN
C. Has a family member ever expressed concern over the money you spend on alcohol or drugs?

YN
HEALTH
Has a health care professional ever:
A. Expressed concerned over your alcohol or drug use?

YN
B. Recommended that you reduce or discontinue use?

YN
Have you ever had any of the following?
A. Stomach Ulcers?

YN
B. High Blood Pressure?

YN
C. Liver disease?

YN
D. Trembling in the morning?

YN
E. Insomnia?

YN
F. A blackout?

YN
G. Increased tolerance to the effects of alcohol or drugs?

YN
H. Have you ever been in counseling?

YN
I. Have you ever used IV drugs?

YN
J. Do you have a family physician?

YN
Name:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
K. Are you on any medication?

YN
PLEASE LIST MEDICATIONS:
FAMILY
Has a family member ever:
A. Expressed concern about your alcohol or drug use?

YN
B. Made excuses for your behavior?

YN
C. Had to drive you because of intoxication?

YN
D. Said that you change after drinking or drug use?

YN
E. Been to Al-Anon?

YN
LEGAL
Have you ever been arrested for any of the following:
A. Alcohol or drug intoxication?

YN
B. Possession of drugs and paraphernalia?

YN
C. Sale of drugs?

YN
D. Any other offense?

YN
PLEASE DESCRIBE:
GENERAL
A. Do most of your friends drink or use drugs?

YN
B. Have you ever attended AA or NA meetings?

YN
C. Have you ever attempted to stop or cut down use?

YN
D. What do you feel are the motivating factors for the other party to make these Accusations?
NOTES (for assessors use):
SUBSTANCE USE HISTORY

Indicate all substances used WITHIN LAST YEAR (Amount and frequency)

Rows	Daily	Weekly	Monthly	Yearly	Never	Amount	Duration	Last Use
Alcohol
Marijuana
Amphetamine
Cocaine
Opiates
Hallucinogens
Inhalants
Tranquilizers

FAMILY HISTORY

Have family members experienced the following

Rows	Mother	Father	Siblings	Grandparents
Alcohol Abuse
Drug Abuse
Depression
Suicide

Were any of the present in your family?
A. Domestic violence?

YN
B. Child Abuse (of yourself)?

YN
C. Child Abuse (of a sibling)?

YN
COLLATERAL CONTACT
Spouse's Name:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Initial:
Father's Name:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Initial:
Mother's Name:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Initial:
Siblings Name:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Initial:
Mediator's Name:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Initial:
Prob/Parole Name:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Initial:
Employer Name:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Initial:
Client Attorney:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Initial:
Spouse Attorney:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Initial:
Other Associate:
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Initial:
I understand that in order to complete a comprehensive, accurate assessment, it may be necessary to contact collateral sources for confirmation of interview data. I hereby release Hill Alcohol and Drug Treatment to contact any or all of the above named individuals to confirm information regarding my use of alcohol or drugs. I hereby waive any rights I hold to confidentially, regarding information I have given to Hill Alcohol and Drug Treatment or its employees. This is in effect for ninety day (90) from the date of signing.
PRINT CLIENT NAME

First NameLast Name
CLIENT SIGNATURE
DATE

MonthDayYear
Date
PRINT WITNESS NAME

First NameLast Name
WITNESS SIGNATURE
DATE

MonthDayYear
Date
I understand that the evaluation I am requesting and for which, Hill Alcohol and Drug Treatment is being compensated, is based on information obtained from myself and other people who may have information related to my use of alcohol or drugs. Some of the information may be objective (I.e. police reports, court document, etc.) or it may be subjective opinions of current or past family members, associated therapists or others.
I understand that the evaluation I am requesting and for which, Hill Alcohol and Drug Treatment is being compensated, is based on information obtained from myself and other people who may have information related to my use of alcohol or drugs. Some of the information may be objective (I.e. police reports, court document, etc.) or it may be subjective opinions of current or past family members, associated therapists or others.
I understand that the evaluator will not be available to debate or amend the report or its contents and any attempts to alter the report by me will be reported to the court and that any written correspondence will be transmitted to the appropriate court. Any threats or efforts to intimidate any employee of Hill Alcohol and Drug Treatment will immediately be reported to the local Police Department.
I have requested this evaluation fully understanding that I may not agree with the finding, impressions or recommendations of the report and the evaluator.
PRINT CLIENT NAME

First NameLast Name
CLIENT SIGNATURE
DATE

MonthDayYear
Date
PRINT WITNESS NAME

First NameLast Name
WITNESS SIGNATURE
DATE

MonthDayYear
Date
Should be Empty:

HILL ALCOHOL AND DRUG TREATMENT COURT ASSESSMENT

CAREER

Have you ever been disciplined or counseled at work for:

FINANCIAL

HEALTH

Has a health care professional ever:

Have you ever had any of the following?

FAMILY

Has a family member ever:

LEGAL

Have you ever been arrested for any of the following:

GENERAL

SUBSTANCE USE HISTORY

FAMILY HISTORY

Were any of the present in your family?

COLLATERAL CONTACT