CPSS/420 v2

Intake Assessment Form

CPSS/420 v2

Page 2 of 2

Intake Assessment Form

Intake Instructions

Intake staff shall review each completed intake assessment completed for each program participant. The intake assessment may help identify a program participant’s treatment needs, but it is the responsibility of staff to gather additional information in the following areas: Social supports, economic resources (including health insurance or Medicaid availability), the program participant’s family history, education, employment history, criminal history, legal status, medical history, alcohol use and other drug use history, and finally previous treatment programs.

Intake assessments should include the evaluation of substance use disorders; the evaluation of alcohol use disorders, and the assessment of treatment needs. This information is utilized to create client driven, clinically supported treatment plans that are SMART (Specific, Measurable, Attainable, Realist and Timelined)

Client Information

Client’s First Name:

Client’s Last Name:

Date of Birth:

Insurance Type:

Client’s Preferred Name:

Admission Date:

Emergency Contact Information

Emergency Contact:

Relationship:

Contact Address (Street, City, State, Zip):

Contact Phone Number:

Release for Emergency Contact obtained for this time period:

Personal Information

Sex Assigned at Birth

Mention ‘Yes’ against what is relevant:

Male:

Female:

Intersex:

Gender queer:

Gender non-conforming:

Male to female:

Female to male:

Other (Specify):

Unknown or declined to state:

Gender Identity

Mention ‘Yes’ against what is relevant:

Male:

Female:

Intersex:

Gender queer:

Gender non-conforming:

Male to female:

Female to male:

Other:

Unknown or declined to state:

Pronoun Preferred

Mention ‘Yes’ against what is relevant:

Him:

Her:

They:

Other:

Unknown:

Referral Reason

Why has the client been referred?

Treatment counselor:

Alcohol and Drug History

Fill in appropriate details for each.

Check if ever used:	Age at first use:	None or denies	Current Use	Current Abuse	Current Dependence	In Recovery	Client-perceived Problem? Write Y or N
Alcohol
Amphetamines (Speed/Uppers, etc.)
Cocaine/Crack
Opiates (Heroin, Oxy, Methadone, Suboxone)
Hallucinogens (LSD, Mushrooms, Ecstasy, Molly)
Sleeping pills, Benzos, Valium, or similar
PSP (Phencyclidine) or Designer Drugs (GHB)
Inhalants (paint, gas, glue, aerosols)
Marijuana, Hashish. DABS
Tobacco, nicotine, vaping, chew
Caffeine (energy drinks, sodas, coffee, etc.)
Over the counter
Other substances
Complimentary alternative medication

Previous Drug and/or Alcohol Treatment History:

Type of Previous Recovery Treatment (Inpatient, Outpatient, Residential, Detoxification)	Name of Previous Treatment Facility	Dates of Previous Treatment	Treatment Completed (Yes or No)

Medical History:

Medical Provider	Name:	Phone #:	Last Date of Service:
Primary Physician:
Other medical provider(s)

Date records requested:

From whom, if applicable:

Relevant Medical History

General Info:

Baseline weight:

Weight changes:

BP:

Mention ‘Yes’ wherever relevant

Condition	Cardiovascular	Respiratory	Genital, urinary, bladder	Gastro-intestinal bowel	Nervous system	Musculoskeletal	Gyneco logy	Skin	Endocrine
Chest pain
Hypertension
Hypotension
Palpitation
Smoking
Bronchitis
Asthma
COPD
COVID
Incontinence
Nocturia
UTI
Retention
Urgency
Heartburn
Diarrhea
Constipation
Nausea
Vomiting
Ulcers
Pancreatitis
Headache
TBI/LOC
Seizures
Memory
Concentration
Back pain
Broken bones
Arthritis
Mobility issues
Pregnant
STD
Menopause
Scar
Lesion
Lice
Dermatitis
Burns
Diabetes
Thyroid
Significant accident
Injuries
Surgeries
Hospitalizations
Physical disability
Chronic illness
HIV
Liver disease

Write details against what is relevant:

Significant accident

Injuries:

Surgeries:

Hospitalizations:

Physical disability:

Chronic illness:

HIV:

Liver disease:

Alternative healing practice/date

For example, acupuncture, herbs, supplements, etc.

Date:	Provider/Type:	Reason for Treatment:	Outcome (Was it helpful and why)

Current/ Previous Medications

(Include all prescribed, OTC, holistic/alternative remedies)

Rx Name	Effectiveness Side Effects	Dosage	Date Started	Prescriber	Current	Past	Psychotropic or Nonpsychotropic

Allergies/Adverse Reactions/ Sensitivities:

Food:

Drugs (Rx/OTC/ILLICT):

Unknown:

Other:

Date of last physical exam:

Date of last dental exam:

Referral made to primary care or specialty (Yes or No. If yes, list):

1.

2.

3.

Additional Medical Information:

Mental Health History

Psychiatric Hospitalizations

Yes or No:

Outpatient Treatment

Yes or No:

Risk factors

Mention ‘Yes’ against what is relevant:

Aggressive/Violent Behaviors:

Self-Harm:

Client referred to crisis services line:

Mental health disorders that are pre-existing, contribute to substance use/abuse, or have been exacerbated by substance use:

Psychosocial History

Family problems that are contributing to, or are exacerbated by, substance abuse. Mention ‘Yes’ against what is relevant and describe below:

Arguments:

Domestic violence:

Family abuses alcohol/drugs:

Family worried about client’s use of drugs/alcohol:

Separated or divorced:

Describe Problems Contributing to Substance Abuse

Social problems that are contributing to, or are exacerbated by, substance abuse. Describe below and check severity:	Mild Y/N	Moderate Y/N	Severe Y/N

Describe economic problems that are contributing to, or are exacerbated by, substance use:	Mild Y/N	Moderate Y/N	Severe Y/N

Describe cultural factors which may influence presenting problems: (may include ethnicity, race religion, spiritual practice, sexual orientation, gender identity, socioeconomic status, living environment, etc.:	Mild Y/N	Moderate Y/N	Severe Y/N

Describe educational problems that are exacerbated by substance abuse:	Mild	Moderate	Severe

Highest level of education completed:

Employment History

Client currently employed? (Yes/ No):

If so, list employer and job:

1.

2.

Problems Caused by Substance Abuse:

Add “Yes” after anything substance use/abuse has caused or contributed to:

Absenteeism:

Tardiness:

Accidents:

Working while hung-over:

Trouble concentrating:

Decreased job performance:

Consumed substances while at work:

Lost job due to substance abuse:

No work problem:

Comments:

Criminal History/Legal Status

Criminal History Table

Criminal justice history/violent incidents of individual and/or family:	Within last 90 days (Yes or No)	Past (Yes or No)
Assault on persons (DV)
Threat to persons
Property damage
DUI

Legal Status Table

Legal history:	Within last 90 days (Yes or No)	Past (Yes or No)
Probation
Parole
Adjudicated
Diversion

Other:

Describe criminal justice involvement.

Note: More space is provided in the Addendum

Date	Type of crime	Outcome	Other

Describe any relevant family involvement with criminal justice.

Note: More space is provided in the Addendum

Date	Relation to client	Type of crime	Outcome	Other

Personal History

Write ‘Not Applicable’ if not applicable.

Client currently in a relationship? If yes, list length or other comments below:

History of sexual abuse?

History of physical abuse?

Does client have children? If yes, list age of each below:

Child 1:

Child 2:

Child 3:

Child 4:

Child 5:

Describe assessed knowledge of parenting skills.

Describe assessed education/knowledge of harmful effects that alcohol and drugs have on the caregiver and fetus, or caregiver and infant.

List parenting skills most needed.

Does client need or will client receive childcare? Answer yes or no:

Client needs to access the following ancillary services which are medically necessary. Provide comments below: (Mention ‘Yes’ against what is relevant)

Dental services:

Social services:

Community services:

Educational/Vocational training:

Transportation (or arranging for) to and from medically necessary treatment:

Other: Specify:

Clinical Formulation

Instructions: Consider all information gathered in the intake assessment for the treatment plan formulation. The formulation should identify each problem that is contributing to client’s alcohol or substance use disorder. All issues identified during the intake assessment process must be listed as a problem statement on the treatment plan (SMART goals). However, some problem statements can de deferred as determined appropriate by the treatment staff.

Addendum

Use this area to report additional criminal justice involvement, etc.

Copyright 2021 by University of Phoenix. All rights reserved.

Copyright 2021 by University of Phoenix. All rights reserved.