Skip Navigation

Link to  the National Institutes of Health  
The Science of Drug Abuse and Addiction from the National Institute on Drug Abuse Archives of the National Institute on Drug Abuse web site
Go to the Home page
   

Home > Publications > A Community Reinforcement Approach: Treating Cocaine Addiction

A Community Reinforcement Approach: Treating Cocaine Addiction



Exhibit 7: Intake Worker Summary

Patient: D.O.B.: Date:

  1. Current Drugs Used (list):
  2. Referred by:
  3. Presenting problem according to patient:
  4. Drugs patient wants help with:
  5. Pattern of use over last 6 months:
  6. Current DSM-III-R drug dependence (list):
  7. Current DSM-III-R drug abuse (list):
  8. Current DSM-III-R dependence/abuse :

    drug yrs used route pattern of use last 6 months (daily, w/friends, etc.)
           
           
           
           

  9. Past DSM-III-R dependence/abuse (list):
  10. Prior drug abuse treatment (list date/type):

     

  11. Employment (circle one):    full    part-time    unemp.;    type of work        pattern last year:
  12. Education completed (specify grade, Assoc., B.A., Voc. training):
  13. Marital status (circle one):    single    married    divorced    widowed    live-in partner
  14. Children (circle one):    yes    no;    ages:
  15. Current living situation (list persons in home):

     

  16. Legal status (ASI):
    Was entry into program forced through legal situation?    yes    no
    Is legal status related to drugs?    yes    no
  17. Medical issues (ASI):
  18. Psychiatric issues (ASI): Suicidal thoughts (circle one):     yes     no;    Past attempts:
  19. MAST Score:
  20. BECK score
  21. ASI Scores: Alcohol:        Drug:        Medical:        Legal:        Fam/Soc:        Psych:

 

[Use the Back Button on Your Browser to Return to the Previous Page]


Therapy Manuals for Drug Abuse:
Manual 2

 



 
TX  
TX
 
 

Contents



Archive Home | Accessibility | Privacy | FOIA (NIH) | Current NIDA Home Page
National Institutes of Health logo_Department of Health and Human Services Logo The National Institute on Drug Abuse (NIDA) is part of the National Institutes of Health (NIH) , a component of the U.S. Department of Health and Human Services. Questions? See our Contact Information. . The U.S. government's official web portal