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* 1. Please complete the information below.

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* 2. Marital Status

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* 3. Children in YOUR custody

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* 4. Referred by:

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* 5. Current charge(s) and legal status (Pre-trial, Probation, etc.):

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* 6. Recent Substance History: Alcohol

Date

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* 7. Recent Substance History: Alcohol
Frequency of Use

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* 8. Recent Substance History: Marijuana

Date

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* 9. Recent Substance History: Alcohol
Amount Used

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* 10. Recent Substance History: Marijuana
Frequency of Use

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* 11. Recent Substance History: Marijuana
Amount Used

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* 12. Recent Substance History: Opioids (heroin, pain pills)

Date

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* 13. Recent Substance History: Opioids (heroin, pain pills)
Frequency of Use

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* 14. Recent Substance History: Opioids (heroin, pain pills)
Amount Used

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* 15. Recent Substance History: Stimulants (cocaine, meth, Adderall)

Date

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* 16. Recent Substance History: Stimulants (cocaine, meth, Adderall)
Frequeny of Use

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* 17. Recent Substance History: Stimulants (cocaine, meth, Adderall)
Amount Used

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* 18. Recent Substance History: Sedative (Xanax, Klonopin, Ativan, Valium)

Date

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* 19. Recent Substance History: Sedative (Xanax, Klonopin, Ativan, Valium)
Frequency of Use

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* 20. Recent Substance History: Sedative (Xanax, Klonopin, Ativan, Valium)
Amount Used

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* 21. Recent Substance History: Hallucinogens (mushrooms, LSD)

Date

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* 22. Recent Substance History: Hallucinogens (mushrooms, LSD)
Frequency of Use

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* 23. Recent Substance History: Hallucinogens (mushrooms, LSD)
Amount Used

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* 24. Recent Substance History: Synthetic drugs (bath salts, spice)

Date

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* 25. Recent Substance History: Synthetic drugs (bath salts, spice)
Frequency of Use

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* 26. Recent Substance History: Synthetic drugs (bath salts, spice)
Amount Used

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* 27. Recent Substance History: Other drugs, including abuse of prescriptions

Date

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* 28. Recent Substance History: Synthetic drugs (bath salts, spice)
Frequency of Use

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* 29. Recent Substance History: Synthetic drugs (bath salts, spice)
Amount Used

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* 30. Current Concerns: Sleep

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* 31. Current Concerns: Lost interest in things you used to enjoy?

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* 32. Current Concerns: Guilt?

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* 33. Current Concerns: Lack of energy?

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* 34. Current Concerns: Problems with concentration?

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* 35. Current Concerns: Worry more than others?

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* 36. Current Concerns: Anger?

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* 37. Current Concerns: Elated mood (feel too happy, out of control of behavior)?

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* 38. Current Concerns: See or hear things other don't?

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* 39. Current Concerns: Appetite change, gained/lost weight?

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* 40. Current Concerns: Any thoughts of harming yourself?

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* 41. Current Concerns: Any thoughts of harming others?

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* 42. Current Concerns: Have you EVER done anything to harm yourself? (Cut self/suicide attempt?)

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* 43. Currently receiving behavioral health or substance abuse services?

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* 44. Currently taking medications prescribed by a doctor?

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* 45. Ever hospitalized for a behavioral health reason such as a suicide attempt?

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