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It also documents psychological and emotional symptoms, suicide and harm history, mental health diagnoses and medications, medical conditions and medications, and family-of-origin and ethnic, cultural, and spiritual 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DEMOGRAPHICS  \n\n| Legal Name: |  |  |\n| --- | --- | --- |\n| Age: | Date ofBirth: | Social Security \\#: |\n| Race: □ Caucasian □ Black □ Hispanic □ Native American □ Other: |  |  |\n| Current Address:\u003Cbr>Street:\u003Cbr>City/State:\u003Cbr>Zip: |  | Current Phone:\u003Cbr>Home:\u003Cbr>Cell: |\n| Emergency Contact: |  | Phone: |\n| □ Guardian □ Representative payee □ Personal representative\u003Cbr>Name:   Phone:   |  |  |\n| Insurance Information: □ Medicaid □ Medicare □ Blue Cross/Blue Shield □ MiChild\u003Cbr>□ Value Options □ Cigna □ United Behavioral Healthcare □ Aetna\u003Cbr>□ Adult Benefit Waiver □ Medicaid Spend down □ Other  \u003Cbr>□ No Insurance Benefits – current household income:   |  |  |\n\nSUBSTANCE USE HISTORY:  \nConsequences as a result of Drug/Alcohol Use (select all that apply)  \n\n| □ Hangovers | □ Seizures | □ Sleep Problems | □ Drinking & Driving |\n| --- | --- | --- | --- |\n| □ Overdoses | □ Liver Disease | □ Lost Job | □ Stealing for drugs |\n| □ Binges | □ GI Bleeding | □ Left School | □ Arrest |\n| □ Blackouts | □ Increased tolerance (need more to get high) | □ Relationship Losses | □ Jail |\n| □ DTs/Shakes |  | □ Traded sex for drugs | □ Other: |\n\nRisk Taking/Impulsive Behaviors (current or past)– select all that apply  \n\n| □ Gambling | □ Gang involvement | □ Selling drugs | □ Reckless driving |\n| --- | --- | --- | --- |\n| □ Unprotected sex | □ Shoplifting | □ Carry/using weapons | □ Other   |\n\nClient’s thoughts about making changes to substance use:  \n\n| □ Not ready to quit | □ Making plans to quit | □ Quit and need help to prevent arelapse |\n| --- | --- | --- |\n| □ Thinking about quitting | □ Already started making changes |  |\n\nHistory of Substance Abuse Treatment: □ No previous treatment  \n\n| Name of Treatment Program | Type of Treatment | Date of Treatment | Status |\n| --- | --- | --- | --- |\n|  | □ Inpatient\u003Cbr>□ IOP\u003Cbr>□ Outpatient |  | □ Completed\u003Cbr>□ Dropped Out\u003Cbr>□ Other: |\n|  | □ Inpatient\u003Cbr>□ IOP\u003Cbr>□ Outpatient |  | □ Completed\u003Cbr>□ Dropped Out\u003Cbr>□ Other: |\n|  | □ Inpatient\u003Cbr>□ IOP\u003Cbr>□ Outpatient |  | □ Completed\u003Cbr>□ Dropped Out\u003Cbr>□ Other: |\n|  | □ Inpatient\u003Cbr>□ IOP\u003Cbr>□ Outpatient |  | □ Completed\u003Cbr>□ Dropped Out\u003Cbr>□ Other: |\n|  | □ Inpatient\u003Cbr>□ IOP\u003Cbr>□ Outpatient |  | □ Completed\u003Cbr>□ Dropped Out\u003Cbr>□ Other: |\n\nClinical Impression: (Staff use only):  \n4/7/11 RM  \nClient Name:   Page 2  \nPSYCHOLOGICAL/EMOTIONAL:  \nCheck all current symptoms:  \n\n| □ Depressed mood | □ No motivation | □ Sleep problems | □ Hallucinations |\n| --- | --- | --- | --- |\n| □ Frequent crying spells | □ No interest in activities | □ Manic episode | □ Paranoia |\n| □ No energy | □ Changes in weight | □ Panic attacks | □ Thoughts of death |\n| □ Irritable often | □ Feeling worthless | □ Constant worry | □ Obsessions |\n| □ Problems concentrating | □ Hopelessness | □ Anxiety | □ Hyperactivity |\n\nHistory of Suicide Attempts □ No □ Yes When:  How:   History of Hurting Others □ No □ Yes When:   How:   Past/Current Mental Health Diagnosis:   Current Mental Health Medications:   Doctor prescribing medications? Name:   Phone:   Address:   Past Mental Health Medications:   Family history of mental health disorders:  \n\n| Family Member | Diagnosis |\n| --- | --- |\n|  |  |\n|  |  |\n\nHistory of Mental Health Treatment: □ No previous treatment  \n\n| Name of Treatment Program | Type of Treatment | Date of Treatment | Status |\n| --- | --- | --- | --- |\n|  | □ Hospital\u003Cbr>□ Partial Day\u003Cbr>□ Outpatient |  | □ Completed\u003Cbr>□ Dropped Out\u003Cbr>□ Other: |\n|  | □ Hospital\u003Cbr>□ Partial Day\u003Cbr>□ Outpatient |  | □ Completed\u003Cbr>□ Dropped Out\u003Cbr>□ Other: |\n|  | □ Hospital\u003Cbr>□ Partial Day\u003Cbr>□ Outpatient |  | □ Completed\u003Cbr>□ Dropped Out\u003Cbr>□ Other: |\n|  | □ Hospital\u003Cbr>□ Partial Day\u003Cbr>□ Outpatient |  | □ Completed\u003Cbr>□ Dropped Out\u003Cbr>□ Other: |\n|  | □ Hospital\u003Cbr>□ Partial Day\u003Cbr>□ Outpatient |  | □ Completed\u003Cbr>□ Dropped Out\u003Cbr>□ Other: |\n\nClinical Impression: (Staff use only):  \nClient Name:   Page 3  \nMEDICAL:  \n\n| Medic","cbCaigqTfeyMQVKI","https://ap.wps.com/l/cbCaigqTfeyMQVKI","pdf",278622,"English","# Substance Use History\n## Consequences and risk-taking behaviors\n## Readiness to change and prior treatment\n# Psychological/Emotional Assessment\n## Current symptoms and suicide/harm history\n## Mental health diagnosis and medications\n# Medical Assessment\n## Medical conditions, medications, allergies\n# Family of Origin and Background\n## Childhood experiences and upbringing impression\n## Ethnic, cultural, and spiritual background","[{\"question\":\"What information does the questionnaire collect at the start?\",\"answer\":\"It collects legal name, age, date of birth, Social Security number (if applicable), current address, phone numbers, and emergency contact details.\"},{\"question\":\"How is substance use history assessed?\",\"answer\":\"It asks about drug/alcohol consequences, risk-taking or impulsive behaviors, readiness to quit or prevent relapse, and history of substance abuse treatment with program type, dates, and status.\"},{\"question\":\"What psychological and emotional sections are included?\",\"answer\":\"It lists current symptoms to check, records history of suicide attempts and hurting others, and captures past/current mental health diagnoses and medications, including prescribing doctor information.\"}]","CLINTON COUNSELING CENTER - Adult Biopsychosocial Assessment Demographics - Intake Questionnaire | PDF",18]