JDRC Behavioral Health Screening (GI) Question Title * 1. Please complete the information below. Name Date of Birth Phone Number Location (County) OK Question Title * 2. Marital Status Single/Never Married Married Divorced Legally Seperated Domestic Partner Widowed Annulled Polygamous Interlocutory OK Question Title * 3. Children in YOUR custody Yes No Age(s) of children: OK Question Title * 4. Referred by: Self Courts Probation/Parole Attorney Other OK Question Title * 5. Current charge(s) and legal status (Pre-trial, Probation, etc.): OK Question Title * 6. Recent Substance History: Alcohol Date of Last Use Date OK Question Title * 7. Recent Substance History: AlcoholFrequency of Use Daily Weekly Monthly Yearly N/A OK Question Title * 8. Recent Substance History: Marijuana Date of Last Use Date OK Question Title * 9. Recent Substance History: AlcoholAmount Used OK Question Title * 10. Recent Substance History: MarijuanaFrequency of Use Daily Weekly Monthly Yearly N/A OK Question Title * 11. Recent Substance History: MarijuanaAmount Used OK Question Title * 12. Recent Substance History: Opioids (heroin, pain pills) Date of Last Use Date OK Question Title * 13. Recent Substance History: Opioids (heroin, pain pills)Frequency of Use Daily Weekly Monthly Yearly N/A OK Question Title * 14. Recent Substance History: Opioids (heroin, pain pills)Amount Used OK Question Title * 15. Recent Substance History: Stimulants (cocaine, meth, Adderall) Date of Last Use Date OK Question Title * 16. Recent Substance History: Stimulants (cocaine, meth, Adderall)Frequeny of Use Daily Weekly Monthly Yearly N/A OK Question Title * 17. Recent Substance History: Stimulants (cocaine, meth, Adderall)Amount Used OK Question Title * 18. Recent Substance History: Sedative (Xanax, Klonopin, Ativan, Valium) Date of Last Use Date OK Question Title * 19. Recent Substance History: Sedative (Xanax, Klonopin, Ativan, Valium)Frequency of Use Daily Weekly Monthly Yearly N/A OK Question Title * 20. Recent Substance History: Sedative (Xanax, Klonopin, Ativan, Valium)Amount Used OK Question Title * 21. Recent Substance History: Hallucinogens (mushrooms, LSD) Date of Last Use Date OK Question Title * 22. Recent Substance History: Hallucinogens (mushrooms, LSD)Frequency of Use Daily Weekly Monthly Yearly N/A OK Question Title * 23. Recent Substance History: Hallucinogens (mushrooms, LSD)Amount Used OK Question Title * 24. Recent Substance History: Synthetic drugs (bath salts, spice) Date of Last Use Date OK Question Title * 25. Recent Substance History: Synthetic drugs (bath salts, spice)Frequency of Use Daily Weekly Monthly Yearly N/A OK Question Title * 26. Recent Substance History: Synthetic drugs (bath salts, spice)Amount Used OK Question Title * 27. Recent Substance History: Other drugs, including abuse of prescriptions Date of Last Use Date OK Question Title * 28. Recent Substance History: Synthetic drugs (bath salts, spice)Frequency of Use Daily Weekly Monthly Yearly N/A OK Question Title * 29. Recent Substance History: Synthetic drugs (bath salts, spice)Amount Used OK Question Title * 30. Current Concerns: Sleep Yes No If yes, how long/often? OK Question Title * 31. Current Concerns: Lost interest in things you used to enjoy? Yes No If yes, how long/often? OK Question Title * 32. Current Concerns: Guilt? Yes No If yes, how long/often? OK Question Title * 33. Current Concerns: Lack of energy? Yes No If yes, how long/often? OK Question Title * 34. Current Concerns: Problems with concentration? Yes No If yes, how long/often? OK Question Title * 35. Current Concerns: Worry more than others? Yes No If yes, how long/often? OK Question Title * 36. Current Concerns: Anger? Yes No If yes, how long/often? OK Question Title * 37. Current Concerns: Elated mood (feel too happy, out of control of behavior)? Yes No If yes, how long/often? OK Question Title * 38. Current Concerns: See or hear things other don't? Yes No If yes, how long/often? OK Question Title * 39. Current Concerns: Appetite change, gained/lost weight? Yes No If yes, how long/often? OK Question Title * 40. Current Concerns: Any thoughts of harming yourself? Yes No If yes, how long/often? OK Question Title * 41. Current Concerns: Any thoughts of harming others? Yes No If yes, how long/often? OK Question Title * 42. Current Concerns: Have you EVER done anything to harm yourself? (Cut self/suicide attempt?) Yes No If yes, how long/often? OK Question Title * 43. Currently receiving behavioral health or substance abuse services? Yes No If yes, where and for what? OK Question Title * 44. Currently taking medications prescribed by a doctor? Yes No If yes, what medication and doctor? OK Question Title * 45. Ever hospitalized for a behavioral health reason such as a suicide attempt? Yes No If yes, when, where, and why? OK DONE
