National Institute on Drug Abuse
Therapy Manuals for Drug Addiction
A Community Reinforcement Approach: Treating Cocaine Addiction Exhibit 7: Intake Worker Summary
| Patient: |
D.O.B.: |
Date:
|
|
- Current Drugs Used (list):
- Referred by:
- Presenting problem according to patient:
- Drugs patient wants help with:
- Pattern of use over last 6 months:
- Current DSM-III-R drug dependence (list):
- Current DSM-III-R drug abuse (list):
- Current DSM-III-R dependence/abuse :
| drug |
yrs used |
route |
pattern of use last 6 months (daily,
w/friends, etc.) |
| |
|
|
|
| |
|
|
|
| |
|
|
|
| |
|
|
|
- Past DSM-III-R dependence/abuse (list):
- Prior drug abuse treatment (list date/type):
- Employment (circle one): full part-time
unemp.; type of work
pattern last year:
- Education completed (specify grade, Assoc., B.A., Voc. training):
- Marital status (circle one): single
married divorced widowed
live-in partner
- Children (circle one): yes no;
ages:
- Current living situation (list persons in home):
- Legal status (ASI):
Was entry into program forced through legal situation?
yes no
Is legal status related to drugs? yes
no
- Medical issues (ASI):
- Psychiatric issues (ASI): Suicidal thoughts (circle one):
yes no; Past attempts:
- MAST Score:
- BECK score
- ASI Scores: Alcohol:
Drug: Medical:
Legal: Fam/Soc:
Psych:
|
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Information@lists.nida.nih.gov
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