Clinical Evaluation

Alcohol and Drug Clinical Evaluation Short Form

Please complete the form below prior to attending your evaluation meeting. **Confidentiality: The information you give below will be held in strict confidence and will be used for establishing your file. Any misrepresented or false information places you at risk of being re-evaluated (at your cost) or discharged.
Full Name*

First NameMiddle NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Email Address*
Phone Number*

Area CodePhone Number
Completed Risk Reduction (DUI) School?

YesNo
If completed, the date was:

MonthDayYear
Date
Risk Reduction Number
Certificate of Completion
NEEDS Summary Score
Type of Current Employment

Full-timepart-timeSelf-employedHomemakerRetiredDisabledUnemployedStudent
Please list the last three employers, the position held, the dates, and reasons for leaving
If unemployed, please explain for how long, the reason, and if you receive public assistance
Who referred you? (Pretrial officer, probation officer, lawyer, or other person's name):

First NameLast Name
Name of the organization that referred you (if any):
Example: JCS, PPS, SE Corrections, County)
Address of the referral source

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of the referral source

Area CodePhone Number
Fax Number of the referral source

Area CodePhone Number
Arrest date of the last DUI (if any)

MonthDayYear
Date
Do either of the following apply to the last DUI arrest?

BAC UnknownRefused
BAC Level
Example 0.09
Please explain what happened
Reason for being stopped and what happened afterwards
Please let us know any previous arrest dates for any other DUIs:

MonthDayYear
Date
BAC Level
Example 0.09
Please let us know any previous arrest dates for any other DUIs:

MonthDayYear
Date
BAC Level
Example 0.09
Please let us know any previous arrest dates for any other DUIs:

MonthDayYear
Date
BAC Level
Example 0.09
Please let us know any previous arrest dates for any other DUIs:

MonthDayYear
Date
BAC Level
Example 0.09
Do you have any pending DUI's? If yes, please list the arrest date (month/year), BAC Level, or if it was unknown or refused, and what happened (the reason for being stopped and what happened afterwards).
Arrest History (other than DUI) - please list with most recent first: the date (month and year), the charge(s), arresting county, and whether you were convicted of the charge(s), the charge(s) were dismissed, or if you had the charge(s) expunged.
Alcohol and Drug History

Please answer the following questions on the basis of how you have drank alcohol or used drugs in the past 10 years. If you have not been drinking for a length of time, there will be a space to list that in. We need to know how you have drank alcohol or used drugs in the past.
Have you ever had an alcohol or drug evaluation before?
If yes, please tell us when, where, and why was the evaluation done?
Have you ever attended an Alcoholics Anonymous (or CA, NA) meeting?
If yes, was it court ordered?
In a one month (30 days) period, how many days would you typically drink?
Number of days
Each time you drink, how much would you typically drink?
(e.g., one beer, six pack, one shot, pint)
When did you have your last drink?

MonthDayYear
Date
In your lifetime have you ever used: (please select any you have used)

AlcoholMarijuanaAmphetaminesMethamphetaminesCocaineCrack CocaineOpioidsHeroinBenzodiazepinesBarbituratesLSDEcstacyMDMAInhalantsSport drugsOther
Please list the substance used, the age of first use, the quantity of use, and the age of last use for each of the selected drugs above. If you selected other, please list the substance used.
Example: Alcohol, 21, 1 six pack a week, 35.
Have you ever abused prescription drugs?

YesNo
If yes, which ones?

Type a question

Rows	Yes	No
Do you feel you are a normal drinker? ("Normal" - drink as much or less than most other people?)
Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?
Does any near relative or close friend ever worry or complain about your drinking?
Can you stop drinking without difficulty after one or two drinks?
Do you ever feel guilty about your drinking?
Have you ever attended a meeting of Alcoholics Anonymous (AA)?
Have you ever gotten into physical fights when drinking?
Has drinking ever created problems between you and a near relative or close friend?
Has any family member or close friend gone to anyone for help about your drinking?
Have you ever lost friends because of your drinking?
Have you ever gotten into trouble at work because of drinking?
Have you ever lost a job because of drinking?
Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?
Do you drink before noon fairly often?
Have you ever been told you have liver trouble such as cirrhosis?
After heavy drinking have you ever had delirium tremens (D.T.'s), severe shaking, visual or auditory (hearing) hallucinations?
Have you ever gone to anyone for help about your drinking?
Have you ever been hospitalized because of drinking?
Has your drinking ever resulted in your being hospitalized in a psychiatric ward?
Have you ever gone to any doctor, social worker, clergyman or mental health clinic for help with any emotional problem in which drinking was part of the problem?
Have you been arrested more than once for driving under the influence of alcohol?

Should be Empty:

Alcohol and Drug Clinical Evaluation Short Form