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TEDS
Please complete the following assessment. When finished it will send the responses to our admissions department. Thanks!
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1.
Address
Name
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number
2.
Full SSN
3.
What is your race?
White or Caucasian
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Another race
4.
What is your gender?
Female
Male
Trans Male
Trans Female
Gender Non-Conforming
Other (please specify)
5.
Have you ever felt the need to bet more and more money?
Yes
No
6.
Have you ever had to lie to people important to you about how much you gamble?
Yes
No
7.
At this time, how important is receiving treatment for alcohol use?
Not at all
Moderately
Extremely
Clear
8.
At this time, how important is receiving treatment for drug use?
Not at all
Moderately
Extremely
Clear
9.
At this time, how important is receiving treatment for mental health issues?
Not at all
Moderately
Extremely
Clear
10.
Are you a veteran?
Yes
No
11.
Which best describes your current living arrangement:
Alone
Living With Family Member
Living with an unrelated person
Transitional Living/Sober Living
Living with Parents or Siblings
Living with Other
Living with Spouse Only
12.
Do you have a developmental disability?
Yes
No
IF Yes, (please specify)
13.
Have you used tobacco in the last 30 days?
Yes
No
14.
What is your marital status?
Never Married
Married
Widowed
Divorced
Separated
Remarried
Common-Law/Living as Married
15.
How many minor children in your care?
0
1
2
3
Other (please specify)
16.
Have you had children previously removed from your custody or who are currently placed with Department of Family Services?
Yes
No
17.
If yes, how many?
0
1
2
3
Other (please specify)
18.
Which best described your current legal status?
No Legal Status (Never arrested/charged)
Probation
Parole
Pending
19.
Are you currently pregnant?
Yes
No
Not Applicable
20.
In the last 30 days, how many times have you been arrested?
0
1
2
3
Other (please specify)
21.
In your lifetime, how many times have you been arrested for DUI?
0
1
2
3
Other (please specify)
22.
What is your highest level of education completed?
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
GED/HiSET
Technical Education
College (AA,BS,BA)
Graduate
Post-Graduate
23.
If you attended special education classes, please include which best described your situation:
No Special Education
Behavior Disordered Classroom
Educable Mental Retardation
Elementary/Secondary Special Education
Learning Disabled Classroom
Remedial Reading
Resource Room
Special Education (Unspecified)
Special Education Testing Suggested
Special School
Speech Therapy
Trainable Mental Retardation
24.
Are you currently enrolled in school or job training?
Yes
No
25.
What is your current employment status?
Full-time (35+ hours weekly)
Part-time (less than 35 hours weekly)
Sheltered Workshop
Supported Employment
Unemployed
Student
Retired
Disabled
Other (please specify)
26.
What is your current occupation?
Clerical Worker
Craftsman
Laborers
Manager
Operative (Mechanical Industry)
Sales Workers
General Labor
Other (please specify)
27.
What is your current source of income?
Alimony
Child Support
Disability
Employment
Family or Friends
Military
No Income
Public Assistance
Retirement
SSA
SSDI
VA
Unearned Income
Unemployment
Worker's Comp
Other (please specify)
28.
What is your weekly income?
Between $1 and $49
Between $50 and $99
Between $100 and $149
Between $150 and $199
Between $200 and $299
Between $300 and $499
Over $500
29.
What is your monthly income?
30.
Please check any public assistance that you are currently receiving.
Food Stamps (TANF)
Job Opportunities ad Basic Skills Training
Legal Services for the Poor
Medicaid
Psychiatric Services
Public Housing
SSDI
Substance Abuse Treatment
Unemployment Compensation
Sober-Living/Recovery Housing (SOR)
Unemployment Compensation
VA Disability
Veteran's Pension
Worker's Compensation
31.
Primary Drug of Use
Fentanyl
Opiates
Meth
Cocaine
Marjiauna
Alcohol
Other (please specify)
32.
Route of Delivery
IV
Snorting
Oral-Chew
Oral-Swallow
Boof
Skin-popping
Other (please specify)
33.
Frequency of Use in the last 30 Days
Daily
Once a Week
Several Times a Week
Once a Month
Several Times a Month
No Use in the Last 30 Days
Other (please specify)
34.
Age of Use for Primary Drug
35.
Secondary Drug of Use
Fentanyl
Opiates
Meth
Cocaine
Marjiauna
Alcohol
Other (please specify)
36.
Route of Delivery for Secondary Drug of Use
IV
Snorting
Oral-Chew
Oral-Swallow
Boof
Skin-popping
Not Applicable
Other (please specify)
37.
Frequency of Use in the last 30 Days for Secondary Drug of Use
Daily
Once a Week
Several Times a Week
Once a Month
Several Times a Month
No Use in the Last 30 Days
Not Applicable
Other (please specify)
38.
Age of Use for Secondary Drug
39.
How many detox programs have you attended in your lifetime?
0
1
2
3
4
5
Other (please specify)
40.
How many residential or inpatient substance use treatment programs have you attended in your lifetime?
0
1
2
3
4
5
Other (please specify)
41.
How many outpatient programs have you attended in your lifetime?
0
1
2
3
4
5
Other (please specify)
42.
What is your primary source of payment?
Self-Pay
Blue Cross/Blue Shield
Medicaid
Other Gov (Unless told otherwise, This will be what you Choose)
Workers Compensation
Other Insurance
43.
In the last 30 days, how many days have you attended a self-help program?
0
1-2 Weekly
3-5 Weekly
Daily
Other (please specify)
44.
What medication are you currently taking for addiction treatment?
None
Naltrexone
Buprenorphine
Disulfiram
Naloxone
Suboxone
Vivitrol
Anti-Depressants
Benzos
Methadone
Other (please specify)
Current Progress,
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