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NIDA 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:

 

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Therapy Manuals for Drug Abuse:
Manual 2

 



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