Client Information

Client Name*
First Last
Birthdate*
MM slash DD slash YYYY
Age*
Are you (the client) 18 years of age or older?*
- Yes
- No
What are the problems you are experiencing?*
When did the problem(s) start ?*
Tell us about your family and the people who live with you.*
What has been done in the past to try and solve the problem(s)?*
- Individual Therapy
- Family Therapy
- Group Therapy
- Medication Therapy
- Substance Abuse Treatment
- Self Help Groups
- Partial Hospitalization
- Psychiatric Hospitalization
- Therapeutic Foster Care
- Other
- None of the above
What is the date you were released from the hospital?
MM slash DD slash YYYY
Who could help or support you in making changes in your life?*
- Mother
- Father
- Step-parent
- Spouse or partner
- Foster parent
- Grandparent
- Aunt and Uncle or other family member
- Children
- Friend(s)
- I do not have any supportive people in my life.
- I do not need support.
- Other
Have you experienced any of the following risks to safety?*
- Suicidal thoughts or feelings
- Made plans to hurt yourself
- Attempted suicide in the past
- Cut or intentionally injured yourself
- Thoughts or feelings of harming someone else.
- Previous aggressive acts toward others
- Episodes of alcohol intoxication
- Episodes of impulsive behavior
- Set things on fire
- Psychosis or delusions
- Sexual offending behavior
- Coping with significant loss such as a job or relationship.
- Partner violence
- Dislike of one’s own body or gender
- None of the above
Have you ever been diagnosed with or suspected you have ADD or ADHD ( Attention Defiicit Hyperactive Disorder)*
- Yes
- No
Screening for ADHD
In the past 7 days have you experienced any of the following:
1. I failed to give close attention to details or made careless mistakes in schoolwork, work, or other activites.
2. I often have difficulty sustaining my attention in tasks or play activities.
3. I often do not seem to be listening when spoken to directly.
4. I often do not follow through on instructions and fail to finish schoolwork, chores, or duties.
5. I often have difficulty organizing tasks and activities.
6. I often avoid, dislike or an reluctant to engage in tasks that require sustained mental effort such as school or homework.
7. I often lose things necessary for tasks or activities such as toys, school assignments, pencils, books, or tools.
8. I am often distracted by extraneous stimuli such as sounds or sights.
Total Score
Are you experiencing symptoms of depression?*
- Yes
- No
PHQ-9 Depression Assessment tool
Over the past 2 weeks how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things.
2. Feeling down, depressed or hopelelss.
3-Trouble falling asleep, staying asleep, or sleeping too much.
4-Feeling tired or having little energy
5-Poor appetitie or over eating
6-Feeling bad about yourself-or that you're a failure or have let yourself or your family down
7-Trouble concentrating on things, such as reading the newspaper or watching television
8-Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figity or restless that you have been moving around a lot more than usual.
9-Thoughts that you would be better off dead or hurting yourself in some way.
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Total Score
Scoring your depression on the PHQ-9 assessment tool
Have you ever experienced problems or complaints about your alcohol use?*
- Yes
- No
AUDIT Alcohol Screening Tool
1. How often do you have a drink containing alcohol?*
- 0-Never
- 1- Monthly or less
- 2- Two to four times a month
- 3-Two to three times a week
- 4-Four or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
- 0-One or two
- 1- Three or four
- 2- Five or six
- 3-Seven to nine
- 4-Ten or more
3. How often do you have 6 or more standard drinks on one occasion?
- 0-Never
- 1- Less than monthly
- 2- Monthly
- 3-Weekly
- 4-Daily or almost daily
4. How often during the last year have you found tht you were not able to stop drinking once you had started?
- 0-Never
- 1- Less than monthly
- 2- Monthly
- 3-Weekly
- 4-Daily or almost daily
5. How often during the last year have you failed to do what was normally expected of you because of drinking??
- 0-Never
- 1- Less than monthly
- 2- Monthly
- 3-Weekly
- 4-Daily or almost daily
6. How often in the last year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session?
- 0-Never
- 1- Less than monthly
- 2- Monthly
- 3-Weekly
- 4-Daily or almost daily
7. How often in the last year have you had a feeling of guilt or remorse after drinking?
- 0-Never
- 1- Less than monthly
- 2- Monthly
- 3-Weekly
- 4-Daily or almost daily
8. How often in the last year have you been unable to remember what happened the night before because of your drinking?
- 0-Never
- 1- Less than monthly
- 2- Monthly
- 3-Weekly
- 4-Daily or almost daily
9. Have you or someone else been injured because of your drinking?
- 0-No
- 2- Yes, but not in the last year.
- 4-Yes, during the last year.
10. Has a relative, friend, doctor or other healthcare worker been concerned about your drinking or suggested you cut down?
- 0-No
- 2- Yes but not in the last year.
- 4-Yes, during the last year.
Scoring your alcohol use on the AUDIT screening tool
Hidden
Are you experiencing problems associated with alcohol or drug use or are other people complaining about your alcohol or drug use?
- Yes
- No
Hidden
In the past 12 months, how many days did you drink more than a few sips of beer, wine or any drink containing alcohol? Say "0" if none.
Hidden
In the past 12 months, how many days did you use any Marijuana (weed, oil, or hash by smoking, vaping, or in food) or synthetic marijuana like K2, Spice) or vaping THC oil? Put 0 if none.
Hidden
In the past 12 months how many days did you use anything else to get high (like other illegal drugs, prescription or over-the-counter medications, and thing that you sniff, huff, or vape)? Put ) if none.
Have you experienced problems or complaints related to your recreational drug use?
- Yes
- No
Drug Abuse Screening Test, DAST-10
The following questions concern information about your possible involvement with drugs not including alcoholic beverages over the past 12 months. Drug abuse refers to the use of prescription or over the counter drugs in excess of the directions, and any non=medical use of drugs. The various classes of drugs may include cannabis (marijuana, hash), solvents (e.g., paint thinner), tranquilizers (e.g.,Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogenics (e.g., LSD) or narcotics (e.g., heroin).
1. Have you used drugs other than those required for medical reasons?
- Yes
- No
2.Do you abuse more than one drug at a time?
- Yes
- No
3. Are you unable to stop abusing drugs when you want to?
- Yes
- No
4. Have you ever had blackouts or flashbacks as a result of drug use?
- Yes
- No
5. Do you ever feel bad or guilty about your drug use?
- Yes
- No
6. Does your spouse (or parents) ever complain about your involvement with drugs?
- Yes
- No
7. Have you neglected your family because of your use of drugs?
- Yes
- No
8. Have you engaged in illegal activities in order to obtain drugs?
- Yes
- No
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
- Yes
- No
10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?
- Yes
- No
Scoring for DAST
Score 1 point for each question you answered "yes" except for question 3 for which a "no" receives 1 point.
Interpretation of DAST Score
Have you experienced any of the following traumas? Adults, please include your childhood experiences.*
- Physical Abuse
- Physical Neglect
- Sexual Abuse
- Emotional Abuse
- Witnessed Abuse
- Family violence
- Violence in your community
- Injured someone else.
- Injured or hit by a partner
- Incarcerated
- Suicide of family member or friend
- Murder of a family member or friend
- Adopted
- Illness of Parent
- Parent or caregiver with a mental illness
- Parent or caregiver with a drug use or too much alcohol
- Changes in your primary caregive as a child
- Unplanned pregnancy
- Death of a loved one
- Fostercare as a child
- Incarcerated parent
- Multiple moves
- Homelessness or problems with housing
- Worries about having enough food.
- Other
- I am not aware of any trauma expereinces.
Height
Weight
What are your health risks or concerns?*
- Abnormal Developmental Milestones
- Addiction to Substances
- Alcoholism
- Asthma
- Blackouts
- Cancer
- Chronic Illness
- Chronic Pain
- Colitis
- Diabetes Type One
- Diabetes Type Two
- Disease of Female Organs
- Emphasemia
- Fasting for Weight Loss
- Fybromyalgia
- Generic Disorder
- Head Injury
- Heart Attack
- Hepititis
- High Blood Pressure
- HIV
- Hormone Problems
- Immunizations are unknown or not up to date.
- Irritable Bowel Syndrome
- Kidney Disorder
- Liver Disorder
- Lung Disorder
- Lupus
- Surgeries
- Menopause
- Obesity
- Prenatal exposure to alcohol or drugs
- Seizures
- Thyroid Problems
- Ulcers
- Vomiting for Weigth Loss
- Other
- There are no health risks known at this time.
Medications*
- I am not currently prescribed medicatons.
- I am currently prescribed medicatons.
How many medications are you prescribed?
1. Medication/dosage/frequency
What date did you start taking this medication?
MM slash DD slash YYYY
Why were you prescribed this medication?
- For symptoms of ADHD or ADD
- Depression
- Anxiety
- To stabilize my mood
- Hallucinations
- Compulsive thoughts or behaviors
- Delusions
Which type of doctor prescribed this medication?
- Primary Care Physican
- Psychiatrist
Do you take this medication as prescribed?
- Yes, I take this medication as prescribed.
- I am inconsistent and do not always take this mediation.
- No, I am not currently taking this medication.
- I am experiencing negative side effects from this medication.
- I am having difficulty abstaining this medication.
What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.
If this medication does not require a follow-up appointment, please inform your therapist.
MM slash DD slash YYYY
2. Medication/dosage/frequency
2. What date did you start taking this medication?
MM slash DD slash YYYY
2. Which type of doctor prescribed this medication?
- Primary Care Physican
- Psychiatrist
2. Why were you prescribed this medication?
- For symptoms of ADHD or ADD
- Depression
- Anxiety
- To stabilize my mood
- Hallucinations
- Compulsive thoughts or behaviors
- Delusions
2. Do you take this medication as prescribed?
- Yes, I take this medication as prescribed.
- I am inconsistent and do not always take this mediation.
- No, I am not currently taking this medication.
- I am experiencing negative side effects from this medication.
- I am having difficulty abstaining this medication.
2. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.
If this medication does not require a follow up appointment, please inform your therapist.
MM slash DD slash YYYY
3. Medication/dosage/frequency
3. What date did you start taking this medication?
MM slash DD slash YYYY
3. Which type of doctor prescribed this medication?
- Primary Care Physican
- Psychiatrist
3. Why were you prescribed this medication?
- For symptoms of ADHD or ADD
- Depression
- Anxiety
- To stabilize my mood
- Hallucinations
- Compulsive thoughts or behaviors
- Delusions
3. Do you take this medication as prescribed?
- Yes, I take this medication as prescribed.
- I am inconsistent and do not always take this mediation.
- No, I am not currently taking this medication.
- I am experiencing negative side effects from this medication.
- I am having difficulty abstaining this medication.
3. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.
If this medication does not require a follow up appointment, please inform your therapist.
MM slash DD slash YYYY
4. Medication/dosage/frequency
4. What date did you start taking this medication?
MM slash DD slash YYYY
4. Why were you prescribed this medication?
- For symptoms of ADHD or ADD
- Depression
- Anxiety
- To stabilize my mood
- Hallucinations
- Compulsive thoughts or behaviors
- Delusions
4. Which type of doctor prescribed this medication?
- Primary Care Physican
- Psychiatrist
4. Do you take this medication as prescribed?
- Yes, I take this medication as prescribed.
- I am inconsistent and do not always take this mediation.
- No, I am not currently taking this medication.
- I am experiencing negative side effects from this medication.
- I am having difficulty abstaining this medication.
4. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.
If this medication does not require a follow up appointment, please inform your therapist.
MM slash DD slash YYYY
5. Medication/dosage/frequency
5. What date did you start taking this medication?
MM slash DD slash YYYY
5. Which type of doctor prescribed this medication?
- Primary Care Physican
- Psychiatrist
5. Why were you prescribed this medication?
- For symptoms of ADHD or ADD
- Depression
- Anxiety
- To stabilize my mood
- Hallucinations
- Compulsive thoughts or behaviors
- Delusions
5. Do you take this medication as prescribed?
- Yes, I take this medication as prescribed.
- I am inconsistent and do not always take this mediation.
- No, I am not currently taking this medication.
- I am experiencing negative side effects from this medication.
- I am having difficulty abstaining this medication.
5. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.
If this medication does not require a follow up appointment, please inform your therapist.
MM slash DD slash YYYY
6.Medication/dosage/frequency
6. What date did you start taking this medication?
MM slash DD slash YYYY
6. Which type of doctor prescribed this medication?
- Primary Care Physican
- Psychiatrist
6. Why were you prescribed this medication?
- For symptoms of ADHD or ADD
- Depression
- Anxiety
- To stabilize my mood
- Hallucinations
- Compulsive thoughts or behaviors
- Delusions
6. Do you take this medication as prescribed?
- Yes, I take this medication as prescribed.
- I am inconsistent and do not always take this mediation.
- No, I am not currently taking this medication.
- I am experiencing negative side effects from this medication.
- I am having difficulty abstaining this medication.
6. What is your next scheduled follow-up appointment? If you do not have a date, please contact your doctor’s office to schedule an appointment.
If this medication does not require a follow up appointment, please inform your therapist.
MM slash DD slash YYYY
7 or more medications
Please provide the requested information for you remaining prescriptions.
Sleep Habits*
- My sleep is within normal range.
- I don't get enougn sleep.
- I sleep too much
Diet*
- I eat a balanced healthy diet.
- I eat a lot of junk food.
- I over eat.
- I worry about my diet.
- I skip meals.
Activity Level*
- I prefer physically actives like walking or playing a sport.
- I prefer passive activies like TV, reading & video games
Nicotine Use*
- I smoke cigarettes.
- I use dip or chewing tobacco products.
- I use e-cigarettes.
- My parents or caregiver suspects I use nicotine.
- I do not use tobacco products
Substance Use*
- I have recently participated in recreational substance use.
- I have participated in recreational substance use in the past.
- My parents or guardian suspect I use recreational substances.
- I have never participated in recreational substance use.
Alcohol Use*
- I use alcohol occasionally or regularly.
- I have used alcohol in the past.
- I have never used alcohol.
- My parents or guardian suspects alcohol use.
- I chose to not drink alcohol.
Alcohol Use*
Check all that apply.
- I drink alcohol occasionally or regularly.
- I get intoxicated occasionally or regularly
- I used to have a drinking problem
- I am concerned that my alcohol use maybe a problem
- I chose to not drink alcohol.
- I have had alcohol related arrests.
Sexuality Identity and Orientation*
- Biological Male
- Biological Female
- Hermaphrodite
- Identify myself as a male
- Identifiy myself as a female
- I have a non-binary gender identitiy
- Heterosexual
- Homosexual
- Bisexual
- Pan Sexual
- A-sexual
- Transgender
- Undeterminend
- Other
Sexual Activity*
- I am sexually active
- I am not sexually active
- I am experincing sexual functioning problems.
- unknown
Have you started Puberty yet?*
- Yes
- No
- Unknown
Do you have access to birth control or know how to obtain it?*
- Yes
- No
What is your current grade level?*
How is your grade performance?
- My grades are average
- My grades are below normal
- My grades are above average
What is your highest level of education?*
- Grade school
- Middle school
- Some high school
- GED
- High school graduate
- Trade school
- Some college
- Associates degree
- College graduate
- Masters degree
- Doctorate or PH. D.
Major or area of specialty
Name of School
Behavioral Impact on Education
- IEP
- 504 Plan
- Classroom accommodations
- truancy/ attendance
- suspension/discipline
- alternate school placements
- home school
- advanced program,
- not attending school
- other
- No known impact on education
Language and Communication*
- I have hearing needs
- I have vision needs
- English is my second language
- I have a preference for a language other than English.
- I need a translator
- I have problems communicating
- I use aids to communicate
- I don't have communication needs.
Vocational and Employment*
- I have self care skills appropriate for my age.
- I would benefit from skills training.
- I have career goals
- I am employed
Vocational and Employoment*
- I am employed
- I am unemployed.
- Unemployment is a problem for me.
- I enjoy my job/career
- I am experincing work related problems.
- I would benefit from Vocational Rehabilitation Services
- I am active duty or retired military.
Where do you work and what do you do?*
Legal*
- Custody order
- DJJ envolvement
- CDW
- DCBS custody
- Legal offenses
- Client has a legal representative
- No known legal history
- CPS involvement/ open CPS case
Legal*
- Custody order
- Divorce
- Civil suite
- Probation or Parole
- Children in DCBS custody
- Legal offenses
- I have an attorney or a legal representative
- Cilhd Protective Serviceis is involved with my family
- No legal history or civil suits or arrests
Disability Determination*
- I am applying for Social Security Disability.
- I am receiving Social Security Disability
- I have no plans to apply for Social Security Disability
Financial Resources*
- My financial resources are adequate to meet the needs of myself and my family.
- I would benefit from resource assistance such as food and housing.
- I am homeless.
Social Relationships*
- I have difficulty developing pro-social skills with peers.
- i have difficulty developing pro-social skills with authority figurues.
- I have difficult with intimate partner relationship skills.
- My social skills are not a concern.
Culture and Ethnicity*
- White
- Black
- American Indian
- Hispanic or Latino
- Other
- I identify with the white majority culture.
- I identify with a minotrity culture.
My ethnicity is.....*
My minority is group is......*
Recreational and Leisure Skills/Strengths*
- I have hobbies and special interests
- I have lost interest in my hobbies and interests.
Describe the hobbies and things you have enjoyed doing now or in the past .*
Spirituality and Religion*
- I am active with a religious organization
- I experience spirituality or religion as a sigificant resource of support.
- I do not see spirituality or religion as a significant resource or support
- I experienced religious abuse
What is the name of your religious organization?
I would describe my community or neighborhood as
- Stable
- Distressed
- Threatening
Environmental Factors for Home Based Services: I have the following in my home*
- Dog(s) in the home
- Cat(s) in the home
- Bird(s) in the home
- Cigarettes are used in my home
- Gun(s) or other weapons in my home
- Illegal activities in my home
- Recent domestic violence in my family
- Bed bugs in my home
- Other:
- There are no known allergens or risk factors in my home or place of residence.
SED Determination Criteria*
Your provider will complete the following assessment questions with you to see if you are eligible for added services. You can help by checking any problems you experience.
- Significant problems with my thoughts, mood, perception, orientation, memory or behavior
- Significant Impaired functioning in self-care
- Significant impaired functioning in interpersonal relationships
- Impaired functioning family life
- Impaired functioning at school
- Impaired functioning in self direction
- And symptoms have persisted for one year or are judged to be at high risk for continuing for one year
- And/or DCBS has removed the child from the home and has been unable to maintain in a stable setting due to emotional instability
- None of the above
Name of the person who provided this information*
First Last
Email
Enter the email address given to you by your provider.
You may upload a current copy of your insurance card here.
Max. file size: 32 MB.
Submission ID

Save and Continue Later

Client Information

Client Information

Screening for ADHD

PHQ-9 Depression Assessment tool

AUDIT Alcohol Screening Tool

Drug Abuse Screening Test, DAST-10