| First Name * | | | Last Name * | | | E-mail Address: * | | | Telephone * | | | Substance Concerns | Alcohol
Antidepressants (Cymbalta, Effexor, Prozac, Wellbutrin, Trazedone)
Antipsychotics (Klonopin, Risperdal, Seroquel)
Antianxiety (Xanax, Librium, Valium, Ativan)
Benzodiazepines (Valium, Xanax)
Barbiturates (Phenobarbital, Seconal)
Cocaine / Crack
Cough syrup (not as prescribed)
Crystal Methamphetamine (Speed, Crank, Glass, Ice)
Diet pills (Dexadrine)
Diuretics
Food (Anorexia, Bulimia, Binging on sugars or carbohydrates)
GHB
Hallucinogens (Acid, Mushrooms)
Heroin (sniff, smoke, or intravenous)
Hypnotics/sleeping pills (Soma, Ambien)
Inhalants (aerosol, glue)
Marijuana (street or medicinal)
Mood Stabilizers (Depakote, Lithium, Neurontin)
Narcotic (Codeine, Morphine, Opiate, pain killers)
Nicotine (cigarettes, chewing tobacco)
Opiates (Vicoden, Oxycontin)
Stimulants (Amphetamine, Ephedrine, Ritalin)
Tranquilizers/depressants (alcohol, barbiturates, antianxiety meds)
XTC | | Social Changes | Isolating
Loosing old friends
Settling for lesser companions
Divorce/separation | | Physical Changes | Weight, gain/loss
Skin, pale/acne
Runny nose
Red cheeks/nose | | Behavior Changes | Memory loss (black/grey out periods)
Aggressive behavior
Violent episodes
Sleeping more/less
Irresponsible/unreliable
Late frequently | | Mood Changes | Anxious
Depressed
Irritable
Wrestless
Discontent
Antisocial
Argumentative
Paranoia | | Legal Changes | Arrests
Convictions (misdemeanors, felonies)
Domestic/other violent episodes
DUI driving while under the influence
Drunk in public
Possession of controlled substance
Unpaid or unattended to tickets/warrants
Speeding tickets
Parking tickets accumulating | | Financial Changes | Loss of job
Bankruptcy
Foreclosure
Overspending
Debt(s) increasing | | Self-Destructive (Concern regarding any of the following self-destructive/inappropriate risk-taking behaviors) | Gambling
Compulsive Behaviors (over spending, hand washing)
Internet (gambling, porn)
Spending more time at bars
Drinking while driving (two drinks or more)
Driving while taking pills not as prescribed or without a prescription
Mixing substances (using more than one drug simultaneously) | | Medical Changes | Hospitalizations (overdose, psychotic episodes)
New Doctor(s)
New condition(s)
New disease(s)
Elective procedure(s)
Sick/cold/allergies
Runny nose | | Psychiatrict Episodes/Diagnosis | 51/50 (forced lock down unit hold)
ER visit(s)
Delusional/psychotic behavior(s)
Bipolar
Borderline
Depression
Manic
Schizophrenic | | Treatment Needs | Intervention (Addicted person needs help but is refusing to enter rehab)
Detoxification (used typically for daily alcohol and opiate consumption)
Inpatient/Residential care
Dual Diagnosis (addiction and mental health)
Eating disorder care
Psychiatric care
Outpatient care
Counseling services |
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