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Intervention Drug and Alcohol Confidential Assessment Form



Alcohol Drug Abuse Confidential Assessment

Congress passed legislation, and the Department of Health and Human Services issued a set of regulations to protect information about clients' substance use disorder treatment. The law is codified at 42 U.S.C. _290dd-2.

The implementing Federal regulations, Confidentiality of Alcohol and Drug Abuse Client Records, are contained in 42 C.F.R. Part 2 (Vol. 42 of the Code of Federal Regulations, Part 2).

The Federal law and regulations severely restrict communications about identifiable clients by "programs" providing substance use/abuse diagnosis, treatment, or referral for treatment (42 CFR _2.11).

The purpose of the law and regulations is to decrease the risk that information about individuals in recovery will be disseminated and that they will be ostracized or subjected to discrimination.

Contact Information

*Denotes Required Fields

First Name:

*
Last Name:

 
E-mail Address:

*
Phone Number:

*
Cell Phone:

 
State:

 
Who needs assistance?:  
Please Enter Their Name:

 
Select Your Time Zone:

 
Best Time To Call:

 
     

Drug and Alcohol History

 

What Is The Primary Drug of Abuse?

   
 
Method of Intake?

 
What Is The Secondary Drug of Abuse?

 
 
Method of Intake?

 
At What Age Did The User First Take Drugs?

 
How Old Is The User Now?

 
At What Age Did The User's Life Begin To Be Unmanageable?

 
Presently What Are The Resulting Problems of The User's Addiction?  
What Is The Family's Attitude Toward The User's Addiction?  
Does The User Admit To Having A Problem?

  yes  no 
Does the user want help?

  yes  no
     

Treatment History

 

How Many Times Has This User Been In Treatment for Their Addiction?

 
How Many of These Involved The 12-Step (AA/CA/NA Model) Approach To Recovery?

 
Was There Any Success With Any Of These Treatment Episodes, and if so, what was the length of sobriety achieved?

 
     

Medical History

 

Does The User Have Any Known Medical Conditions?

 
If So, Please List The Condition(s) And Any Necessary Details:

 
Has This Person Ever Been Diagnosed With Any Psychiatric Disorders?

 
If so, is He / She Currently On Medication for A Psychiatric Disorder?

 
If So, Please Specify Medications Taken:

 
Does The User Have Medical Insurance?

 
If so, who is the Insurance Carrier?
 
     

Supplemental Background

 

Does The User Have Legal Issues?

 
If So, Please Describe

 
Please Provide Us With Any Other Information and Any Questions You May Have In The Area Below