Substance Abuse Evaluation Form

INSTRUCTION: Please answer all questions below and make explanations as necessary. The words alcohol and drugs are used interchangeably, as are the words drink and use. If you have any questions while completing this history please ask.

After submitting this form give us a call to schedule your appointment.

INSTRUCTION: Please answer all questions below and make explanations as necessary. The words alcohol and drugs are used interchangeably, as are the words drink and use. If you have any questions while completing this history please ask.

Name*

First NameLast Name

AGE*

SEX*

TODAYS DATE

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PHONE*

Phone Number

Please enter a valid phone number.

DOB

EMAIL*

example@example.com

What is Officer's first and last name?

What is Probation Officer email?

1. Have you completed a substance abuse evaluation with us before?

YesNo

2. What was your most recent arrest for?

What date were you arrested?

What county were you arrested in?

Please write all arrests, dates, and counties below:

3.Have you ever used alcohol or other drugs?

YesNo

ALCOHOL

COCAINE

MARIJUANA

METHAMPHETAMINES

HALLUCINOGENS

HEROIN / OPIATES

PERSCRIPTION DRUG ABUSE

OTHER

5. Have you ever tried to cut down on your drug use?

YESNO

6. Have people made you angry by criticizing your drug use?

YESNO

7. Have you ever felt guilty about your drug use?

YESNO

8. Have you ever used alcohol/drugs when waking up in the morning?

YESNO

9. Have you ever drank or used more than you intended?

YESNO

10. Have you ever been hospitalized as a result of your use of alcohol or other drugs? (ie, accident, overdose, etc?)

YESNO

11. How many times in the past year have you consumed four or more drinks in one sitting (for women) Five or more drinks in one sitting (for men)?

YESNO

If you drank or did drugs, how much and how often would you? For example, I would drink 4 12 ounce beers once a week. I would smoke 1 gram of marijuana daily. Please write below answers for every substance used.

12. How many times in the past year have you used an illegal drug or used a prescription medication fornonmedical reasons?

What all have you been arrested for? What was the date of the arrest? Date If you were arrested for a DWI what was your BAC? WILL NEED YOUR BAC FOR DWI ARRESTS.Type a label

13. HOW MANY of these were alcohol/drug related?

14. Have you ever thought about suicide or homicide?

YESNO

15. Are you currently thinking about suicide or homicide?

YESNO

16. Is there a family history of suicide?

YESNO

17. Is there a family history of mental health diagnosis (depression, bi-polar disorder,etc)?

YESNO

18. Is there a family history of substance use disorders?

YESNO

19. When you drink, do you normally drink to intoxication (to get drunk)?

YESNO

20. Have you ever been prescribed methadone, Suboxone, Antabuse, or any other drug to help overcome an addiction?

YESNO

21.Do you think alcohol and other drugs have caused a problem in your life? Yes No If yes, please explain: How?

22.Have you ever been in treatment for an alcohol/drug problem? Yes No If yes, was it: Detox Inpatient Outpatient

23.Have you ever used alcohol or other drugs to relieve or avoid withdrawal symptoms?

YESNO

24. I rate my physical health as being:

25. Are you currently on any medication for physical health problems?

YESNO

26.Have you ever been diagnosed with a mental health disorder (ADHD, depression, etc)? Yes No If yes, please explain:

27. Are you currently on any medication for mental health problems?

YESNO

28. If you are on probation, have you have any positive ua's??

YESNO

29. Have you been in a controlled environment in the past 30 days (jail, hospital)?

YESNO

30. Have you ever been investigated by Child Protective Services (CPS)?

YESNO

31. What is the highest grade you completed?

32. Do you have any learning disabilities?

YESNO

33.Are you employed If unemployed, how long: How long?

34. Where do you work, Part-time or fulltime?

35. What city do you work in?

36. Have you served in the military?

YESNO

37. Have you been in prison?

YESNO

38. Emergency Contact Name? Relation, and Phone number?

Would you like to complete the evaluation in our office at 1836 W Virginia St 105A, McKinney, TX or over the phone. The phone call will last about 45 minutes. You will need to be alone in a quiet place for the phone call. Please write phone or office.

How will you pay the $75 fee? Please call or text us when you're ready to pay at 262-434-0076. We will schedule the appointment at time of payment.

To ensure we can assist other clients, please note that a $50 fee will apply for cancellations made less than 24 hours before your appointment.

There is a sassi questionaire that will be emailed to you. It's sent from sassionline.com. If you do not complete, the counselor cannot call you. Please write YES if you understand. The sassi must be completed the day it is emailed.

Texas Counseling and Education

CRIMINAL JUSTICE CONSENT TO RELEASE INFORMATION

I, First Name Last Name authorize Texas Counseling and Education or agents of, to release the results of my Substance Abuse Evaluation to Community Supervision. This consent extends to the District Attorney's office, if requested, and/or the Texas Department of Family and Protective Services, if requested. I am also giving my consent for these agencies to discuss my case with Texas Counseling and Education, if needed.

I understand the recipient may use this information only in connection with official duties regarding my criminal justice status and may not make it available for general investigations or other unrelated purposes. Further, this information can be re-disclosed and used only to carry out the person's official duties with regard to the court action.

This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2 The federal rules prohibit you from making and further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see 2.31 The federal rules restrict an use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at 2.12(c5) and 2.65.

CLIENT SIGNATURE

DATE

Date

EARLY INTERVENTION PSYCHO-SOCIAL HISTORY

4. If yes, please check the drugs you have used and complete information below