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To be completed by clinician with client, or client's family member when screening indicates SA/CD issues GENERAL SYMPTOMS OF CHEMICAL DEPENDENCY (Check all that apply) Preoccupation Loss of control Blackouts Unable to stop
Daily Use A.M. drinking Pre-drinking Binging
Guilt or remorse Hiding supply Sneaking use Use to reduce stress
Tolerance Prescription abuse Use to reward self
Elaboration (include triggering events):
PHYSICAL – WITHDRAWAL SYMPTOMS OF CHEMICAL DEPENDENCY Tremors High Blood Pressure Ulcers
Delirium (DTs) Hepatitis Gastritis
Seizures Nosebleeds
Other Symptoms:
BEHAVIOR – PERSONALITY CHANGES ASSOCIATED WITH USE Verbal abuse Physical abuse Excessive anger More/less social Embarrassed by behavior during use
Social isolation Labile mood Depression More relaxed Effects on morality or spirituality
Family concerned Work concerned Insomnia Sexual performance Un-kept promises
Elaboration:
FINANCIAL AND LEGAL HISTORY Wages garnished Repossessions Indicate dates of arrest if applicable: DWI-DUI: Burglary: History of probation:
Bankruptcy Suspended license
Legal problems Collection agency involved
Possession: Domestic Violence:
Drug Sales: Other: _________
PROBLEMS IN JOB, SCHOOL OR OTHER ROLE FUNCTIONS Attendance Disciplined Using at work/school
Deteriorating performance Mon or Fri absences Erratic behavior
Promises to improve Accidents/safety violations
Tardiness Argumentative
TREATMENT HISTORY (Indicate dates of treatment) Detoxification: Other:
Outpatient: Inpatient:
Aftercare: Longest abstinence:
SUBSTANCE ABUSE/CHEMICAL DEPENDENCE HISTORY (For client age 12 or over, please complete for each substance used including past use or substances not currently being used. Include over-the-counter medications, prescriptions, controlled substances, nicotine products, and alcohol.) Client reports past history of use but is now abstinent: _____________________________ Substance:
OTHER ADDICTIONS Eating Spending
Amount
Frequency
Gambling Codependency
Age began
Sexual Other
CHEMICAL DEPENDENCY ASSESSMENT SUMMARY Chemical dependency apparent: Yes___ No___ Refer for evaluation of level of care: Yes___ Chemical abuse apparent: Yes___ No___ Clinician Signature
