CLIENT INFORMATION:

Date:  _____________________________________

Name: ___________________________________________________________________________________

Age: ______________________________________             Ethnicity: ________________________________

What problem or crisis led you to seek treatment at the time?
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What do you hope to gain by treatment:
_________________________________________________________________________________________
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ALCOHOL & DRUG HISTORY:

Briefly describe your first use of alcohol and/or other drugs (age, what drug, what happened, where,
with who?):
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_________________________________________________________________________________________
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Describe how your drinking/using progressed or developed from first use to present:
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What substances do you use more often?
_________________________________________________________________________________________
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Have you ever attended AA?    Y      N How long did you attend? _________________________

How many times per week did you attend?  ______________________________________________________

When did you last attend? _____________________________ Did you use a sponsor?    Y     N

Longest period of abstinence in the program? ____________________________________________________

What ways and means have you used to try to stop drinking/using?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Have you tried to control the amount of your drinking/using?    Y      N

What happened?
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How did you try to hide/conceal your drinking/using?
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When do you do most of your drinking/using?
_________________________________________________________________________________________
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How often have you been intoxicated (alcohol) in the past six months?
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How many times have you been "high" in the past six months?_______________________________________

What does drinking/using do for you?
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_________________________________________________________________________________________
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Are you an alcoholic?    Y     N Do you want to stop drinking?    Y     N

What is your definition of an alcoholic?
_________________________________________________________________________________________
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Are you chemically dependant?    Y     N Do you want to stop using?    Y     N

What is your definition of a chemically dependant person?
_________________________________________________________________________________________
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How has the use of alcohol and/or drugs affected the following areas of your life?

Health: (Include accidents/injuries while under the influence, illnesses):
_________________________________________________________________________________________
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Family: (Parents, relatives):
_________________________________________________________________________________________
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Sexuality: (Include changes in desire, frequency, values; also, promiscuity, infidelity, obsession with
pornography, unwanted pregnancies, contraction of sexually transmitted diseases):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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Socially: (Community involvement, change in friends, isolation):
_________________________________________________________________________________________
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Legally: (List all arrest and convictions related to alcohol/drug use):
_________________________________________________________________________________________
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School: (Conflicts with teachers, truancy, failing grades, conflicts with other students, illegal activities):
_________________________________________________________________________________________
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Self Worth: (Describe how your feelings about yourself have changed):
_________________________________________________________________________________________
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Spirituality: (Has your relationship with a higher power changed?):
_________________________________________________________________________________________
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FAMILY OF ORIGIN:

Describe the community/neighborhood you grew up in:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

How would you describe your family:

___________ Well off
___________ Comfortable
___________ Struggling
___________ Poor

Describe your home life as a child:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

What cultural traditions were practiced in your family of origin?
_________________________________________________________________________________________
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What spiritual/religious traditions were practiced in your family or origin?
_________________________________________________________________________________________
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Are you adopted?    Y     N If yes, at what age were you adopted? ____________________

Describe any family history of mental illness or suicide:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Mother:

Occupation: _______________________________________________________________________________

Religion: _________________________________________________________________________________

Ethnicity: _________________________________________________________________________________

Is your mother living?    Y     N                If not, how old were you when she died? _____________________

How did she die?
_________________________________________________________________________________________
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Describe your mother as you remember her as a child:
_________________________________________________________________________________________
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In what ways are you like your mother?
_________________________________________________________________________________________
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Father:

Occupation: _______________________________________________________________________________

Religion: _________________________________________________________________________________________

Ethnicity: _________________________________________________________________________________

Is your father living?    Y     N                   If not, how old were you when he died? _____________________

How die he die?
_________________________________________________________________________________________
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Describe your father as you remember him as a child:
_________________________________________________________________________________________
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In what ways are you like your father?
_________________________________________________________________________________________
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Siblings:

List all of your brothers and sisters:

PARENTS:

How was discipline handled in your family?
_________________________________________________________________________________________
_________________________________________________________________________________________

Were you ever physically abused with discipline by:

Mother:    Y     N Father:    Y     N Someone Else:     Y     N

If so, how:
_________________________________________________________________________________________
_________________________________________________________________________________________

Were you spanked with anything other than by hand?    Y     N

Explain:
_________________________________________________________________________________________
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Were you left alone for any length of time or put in charge of younger siblings prior to age 12?     Y     N

Describe:
_________________________________________________________________________________________
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How did your parents feel about the use of alcohol/drugs?
_________________________________________________________________________________________
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How did your parents get along with each other?
_________________________________________________________________________________________
_________________________________________________________________________________________
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Did they argue?     Y     N Did they have physical fights?    Y     N

Was anyone injured during these fights?     Y     N               Did your parents divorce?     Y     N

If so, how old were you? _________________

Who did you live with? _________________________________________________________________________________________

Did either parent remarry?     Y     N

Which parent were you closest to and why?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Please list and describe other significant people in your life as a child (Grandparent, step parent,
live-in-nanny, etc.):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Please describe briefly any significant childhood events (Death of loves one, verbal abuse, physical abuse,
sexual abuse, serious illness or injury of self or family member, major tragedy, etc.):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Describe your current relationship with your parents:
_________________________________________________________________________________________
_________________________________________________________________________________________
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Describe your current relationship with your siblings:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

CURRENT PEER RELATIONSHIPS

Describe your social support system with peers, significant other an/or other support:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Describe current, significant friendships:
_________________________________________________________________________________________
_________________________________________________________________________________________
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SPIRITUALITY:

Briefly describe your views on spirituality or religion:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Have your views changed as s result of drinking/drug use?     Y     N

How?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

CURRENT FAMILY FUNCTIONING:

Describe your current relationship with your family:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Are they supportive of your recovery?     Y     N

Describe your current neighborhood or community:
_________________________________________________________________________________________
_________________________________________________________________________________________
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LEGAL:

Have you ever been arrested?     Y     N

If yes, charges?
_________________________________________________________________________________________
_________________________________________________________________________________________

Legal problems pending:
_________________________________________________________________________________________
_________________________________________________________________________________________

Are you currently on:

____________ Parole
____________ Probation

Why?
_________________________________________________________________________________________
_________________________________________________________________________________________

Does your probation/parole officer know you are here?     Y     N

MENTAL / EMOTIONAL:

Have you ever had thoughts of suicide?     Y     N

If so, please describe:
_________________________________________________________________________________________
_________________________________________________________________________________________

When was the last time you had these thoughts?
_________________________________________________________________________________________

Have you ever attempted suicide?     Y     N How many times? ________________________

When?
_________________________________________________________________________________________

How did you attempt it?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Have you ever thought you were losing your mind?     Y     N

Explain:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Have you ever had strange or disturbing thoughts?     Y     N

Explain:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Have you ever physically hurt another person?     Y     N

Explain:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

EDUCATION:

Current grade: ____________________________ Current grades: _______________________

School attendance: ________________________ Grades prior to chemical use: _____________

Have you ever been:

____________ Expelled
____________ Suspended

Behavioral problems at school:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Current sports activities:
_________________________________________________________________________________________
_________________________________________________________________________________________

Sport activities prior to chemical use:
_________________________________________________________________________________________
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Current extracurricular activities:
_________________________________________________________________________________________
_________________________________________________________________________________________

Extracurricular activities prior to chemical use:
_________________________________________________________________________________________
_________________________________________________________________________________________

Have you been diagnosed with a learning disability or feel you struggle with learning material that seems
easier for others?    Y     N

Explain:
_________________________________________________________________________________________
_________________________________________________________________________________________

SEXUAL HISTORY:

Sexual orientation/preference:   Heterosexual      Bisexual        Homosexual

At what age did you start having Sex? _____________________

Do you practice protected sex?     Y     N          What percentage of the time? _________________________

Describe any problems or concerns about your sexuality:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Have you been sexually abused?     Y     N

Explain:
_________________________________________________________________________________________
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Have you ever been forced or coerced into sexual activity against your will?     Y     N

Explain:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Have you ever forced or coerced another person into sexual activity against their will?     Y     N

Explain:
_________________________________________________________________________________________
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CLIENT'S PERSPECTIVE:

What are your personal strengths?
_________________________________________________________________________________________
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What are your personal weaknesses?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

What issues do you need to address in treatment to stay sober?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

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