Counselor Intake | Forever Well

Today's Date

Month

Day

Year

First name

Last name

Race

Gender

Age

Reason for seeking treatment:

Substance Use History

Are you transferring your care from another clinic: (Yes/ No) If yes, Please list the provider name, address, clinic name, and how long were you a patient there.

Were you ever discharged from any treatment program: (Yes/ No) If yes Why:

Did you abuse prescription drugs? (Yes/ No)

Yes

No

Substance use-frequency/intensity/duration:

Have you struggled with both Alcohol and/or other drugs: (Yes/ No) If yes, what are some other drugs that you struggle with?

Have you ever tried to quit on your own? (Yes/ No) Please describe:

What age were you when you began using (marijuana, or other illicit substances:

Was your use of illicit substances recreational, or injury related?

Recreational

Injury Related

Did you snort, orally ingest, smoke, and/ or IV use?

Snort

Orally ingest

Smoke

IV use

Do you attend any substance abuse support groups online or in person? If yes, which groups?

Are you facing any legal matters for any illicit substances or/ alcohol abuse? If yes, provide details:

Are you currently on probation either from a (State or Federal) institution? (If yes) for how long?

Did you use a combination of illicit drugs (Yes/ No) If yes what combinations:

How much illicit substances would you consume in a day?

How long have you been or had been using illegal substances or misused prescription drug?

Do you smoke? If yes, how much

Do you want to quit smoking?

Yes

No

Treatment history (Mental Health and Substance Abuse Treatment)

Have you ever been treated for substance dependence or misuse (e.g. detoxification program, Intensive Outpatient Program, Individual Therapy?) (if yes, please describe setting, length):

Have you ever experienced mental, verbal, emotional, physical, and/or sexual abuse? Please describe below:

Social Family History ( Mental Health and Substance Abuse)

Does anyone in your family (mother, father, brother/sister, child, aunt/uncle or grandparent) have a history of substance abuse? If yes, please describe below:

Has anyone in your family (mother, father, brother/sister, child, aunt/uncle or grandparent) ever been diagnosed with a mental health disorder? If yes, please describe below

Mental Health & Sexuality

Do you have trust concerns? If yes, please explain:

Do you have weight concerns?

Yes

No

Are you on diet pills or weight loss injections?

Yes

No

Are you under psychiatric care? Are your needs being met? If yes by whom?

Do you struggle with sexual identity?

Yes

No

How do you sexually self- identify:

Straight

Bi-Sexual

Homosexual

Transgender

Are you a part of any LGBT or QIA support group

Yes

No

Are you sexually active?

Yes

No

Do you use protection?

Yes

No

Are you effectively communicating well with others?

Yes

No

Any relationships in the past abusive? If yes, please explain:

Have you ever attempted suicide? If yes, please explain:

Have you ever felt like you wanted to self-harm ? If yes, please explain:

Have you cut yourself in the past? If yes, please explain:

Do you prefer to be alone:

Yes

No

Have you been clinically diagnosed with depression? If yes, by whom

Have you been clinically diagnosed with anxiety? If yes, by whom

Have you ever physically hurt others? If yes, please explain:

Do you have any other Mental Health concerns: (For example: Bipolar, Schizophrenia, PTSD, Panic Attacks, or Night terrors)

Have you been diagnosed with an eating disorder ?If yes, please explain:

Have you been diagnosed with a sleep disorder?

Narcolepsy

Insomnia

Sleep Apnea

None of the above

Have you ever experienced hallucinations? If yes, please explain:

Have you ever experienced auditory voices? If yes, please explain:

Social History, Educational/Occupational History, and Legal Concerns

Has your substance abuse impacted your relationships, made work difficult for you and/or led to legal issues in the past or currently? (Yes/No) If yes, please describe:

Level of education completed?

Community, Environment & Employment

Do you have a job? (Yes/ No) how long have you had this job?

How many jobs have you worked in over the past 2 years:

Do you attend any religious services:

Yes

No

Are you active in any community volunteer services or any form of community service? (Yes/ No) If yes, please explain:

Are you on disability?

Yes

No

Living situation

Own

Rent

Homeless

Other

Is this a stable accommodation for you? (Yes/ No) If no, please explain:

How long have you lived there?

Do you live with someone: (Yes/ No) if yes, (Who)

Relationships

Where do you live (What County)

What are your relationships like at home?

Is domestic violence, either physical, emotional, or psychological abuse occurring? (Yes/No) If yes, please explain:

Do you feel secure and safe at home? (Yes/No) If no, please explain:

Is your family, and/or friends supportive of your recovery efforts (Yes/No) If no, please explain:

Do you have friends you hang out with?

Yes

No

Have you been incarcerated/ or gone to jail: (Yes/ No) If yes, provide details:

Are you trying to mend broken family relationships (Yes/ No) If yes, please explain:

Medical Conditions

Do you have any medical conditions? (Yes/No) If yes list below and include any medications that you are taking currently as well as the dosage:

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Counselor Pre-Visit Questionnaire