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PS375 | Psychology of Addiction

Assignment Template | Unit 3 TEMPLATE SECTION EXPLANATIONS

Below are explanations of each of the sections on the ASI-Lite template that you will complete. Remember this information when you write your short summaries under each section of the template. The template follows the explanations below. General Information You will find this type of section on every assessment form. The information in this section is important to help you create a profile of the client, to get contact information, and to understand “who” you client is through demographic information. Complete this section using information from the client interview or if the data is missing, make it up. You will find that the questions in this section are straightforward to answer. Employment/Support Status The information that you collect in this area helps with determining the severity of the addiction disorder. Clients who have moderate to severe disorders will report significant issues in this section. It is important to know if your client has a driver’s license or reliable transportation because without it, he/she will find it difficult to come to appointments. If information is not included in the audio interview, you may make it up. The information in this section will be used with information in other sections to determine the severity rating and placement recommendation of the substance use disorder. For example, a client who cannot keep a job and spends most of her day getting, using, and recovering from drug use would have a severe diagnosis (compared to mild or moderate). Alcohol/Drugs The information collected in this section is critical to making a substance use specific diagnosis. You will note the types of drugs used, frequency, amount, combinations, and anything else related to drug/alcohol use history. Legal Status This information is important to know for practical purposes. It helps to identify level of use if the client reports that it is her “fifth DUI” conviction or first arrest. You will also learn if the client is court-mandated (this means your agency needs to bill differently). Of course, it also helps you to understand the level of involvement that the client has with the judicial system. Family/Social Relationships This information in this section helps to identify the client’s role in the family. If the client lives alone, social relationships will be important to explore as a form of primary support. Often, family members or close friends will be concerned about the client. The client

PS375 | Psychology of Addiction

might show frustration with others thinking that he/she has a problem. It is also important to know if the quality of those relationships. Psychiatric Status While your agency will likely not enroll clients, who have severe mental health disorders, it is important to assess the client’s current status. Clients in crisis often suffer from mental health symptoms and those require treatment. This section is already completed for you on your template, but consider the information when making a diagnosis and placement recommendation.

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TEMPLATE INSTRUCTIONS

Remember: This is an interview, not a test If a response is already provided, use it in your overall analysis. If the client did not give a response for a question, you can make it up. Use that information in your analysis too. Interviewer Instructions

1. Leave no blanks

2. Make plenty of comments (if another person reads this ASI, he or she should have a relatively complete picture of the client's perceptions of his/her problems).

3. When writing comments in the summary area at the end of each section, please write the question number.

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TEMPLATE

General Information Date of Admission: 1/23 /2017 Date of Interview: ____________ Gender: Male

Female Transgender

Name: Cheyenne Smith-Jones Address: 123 Main Street Madison, WI, 53703

PS375 | Psychology of Addiction

Telephone Number: (414) 343-9948 How long have you lived at this address? Years ____ Months _____ Date of birth: (Month/Day/Year) What race do you consider yourself?

White (not Hispanic) Hispanic-Mexican Black (not Hispanic) Hispanic-Puerto Rican American Indian Hispanic-Cuban Alaskan Native Other Hispanic Asian/Pacific

Do you have a religious preference?

Protestant Catholic Jewish Islamic Other None

Have you been in a controlled environment in the past 30 days?

No Jail Alcohol/Drug Treat. Medical Treatment Psychiatric Treatment Other: ______________ How many days (approximately)? __________

Employment/Support Status Level of education completed (indicate the highest level achieved): GED = 12 years High School Diploma Training or Technical education. Area of specialization: ______________ College completed. Degree and major _________________ Some college Do you have a valid driver's license? YES NO Do you have an automobile available? YES NO

Does not require ownership, only requires availability on a regular basis.

PS375 | Psychology of Addiction

How long was your longest full time job (does not necessarily mean most recent job)? Years ____ Months ______

Full time = 35+ hours weekly; Usual (or last) occupation? (specify) ______________________________ Does someone contribute the majority of your support? YES NO Usual employment pattern, past three years?

Full time (35+ hours) Service Part time (regular hours) Retired/Disability Part time (irregular hours) Unemployed Student In controlled environment

How troubled or bothered have you been by these employment problems in the past 30 days? ___________________ How important to you now is counseling for these employment problems? _____________________ Employment/Support Comments Include any information that was interesting: The client might mention that she started college, but ended drinking too much to complete her degree. Note client’s strengths too. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Alcohol/Drugs Route of Administration Types:

Oral Nasal Smoking Non-IV injection IV

Past 30 Days Admin- indicate the route of administration

Alcohol (any use at all) # of times in the last 30 days _____ Alcohol (to intoxication) # of times in the last 30 days _____ Heroin # of times in the last 30 days _____ Methadone # of times in the last 30 days _____

PS375 | Psychology of Addiction

Other Opiates # of times in the last 30 days _____ Barbiturates/Sedatives # of times in the last 30 days _____ Cocaine # of times in the last 30 days _____ Amphetamines # of times in the last 30 days _____ Cannabis # of times in the last 30 days _____ Hallucinogens # of times in the last 30 days _____ Inhalants # of times in the last 30 days _____ More than 1 substance per day # of times in the last 30 days _____

How many times in your life have you been treated for: Alcohol use: ______ Drug use: _____

Include detoxification, halfway houses, in/outpatient counseling, and AA or NA (if 3+ meetings within one month period).

How many of these were detox only: Alcohol: _______ Drugs: _____ How much money would you say you spent during the past 30 days on: Alcohol: _______ Drugs: _____ How many days have you been treated as an outpatient for alcohol or drugs in the past 30 days? (Include AA/NA): ___________________ How many days in the past 30 have you experienced alcohol problems: ____ How troubled or bothered have you been in the past 30 days by these alcohol problems: ____________________________ How important to you now is treatment for these alcohol problems: ____________________ How many days in the past 30 have you experienced drug problems: ____ How troubled or bothered have you been in the past 30 days by these drug problems? ___________________________ How important to you now is treatment for these drug problems? ______________ Alcohol/Drugs Comments Include any contradictions or important notes that relate to the client’s substance use. ______________________________________________________________________

PS375 | Psychology of Addiction

______________________________________________________________________ ______________________________________________________________________ Legal Status Was this admission prompted or suggested by the criminal justice system?

YES NO Are you on parole or probation? Note duration and level in comments. YES NO ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ How many of these charges resulted in convictions? _____ Convictions include fines, probation, incarcerations, suspended sentences, and guilty pleas should be noted in comments area. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Legal Comments Include anything that the client stated that was important. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Family/Social Relationships Marital Status:

Married Remarried Widowed

PS375 | Psychology of Addiction

Separated Divorced Never Married

Are you satisfied with this situation? YES INDIFFERENT NO Satisfied = generally liking the situation.

Usual living arrangements (past 3 years): Choose arrangements most representative of the past 3 years.

With sexual partner & children With friends With sexual partner alone Alone With children alone Controlled Environment With parents No stable arrangement With family

Are you satisfied with these arrangements? YES INDIFFERENT NO Do you live with anyone who: Has a current alcohol problem? YES NO Uses non-prescribed drugs? YES NO With whom do you spend most of your free time?

Family Friends Alone

Family/Social Comments Include important information. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Psychiatric Status *assume that this part of the form was completed by a licensed mental health professional. How many times have you been treated for any psychological or emotional problems: In a hospital or inpatient setting? * 12/2/2015 after an argument with her ex-husband, threatened suicide and was admitted for evaluation- 3 days then released.

PS375 | Psychology of Addiction

Outpatient/private patient? *saw a psychiatrist for treatment of mild depression (not formerly diagnosed with depressive disorder though). 12/2/2015- 12/5/2016 Enter diagnosis in comments if known. *Client reported that she did not think that she had a diagnosis, but also thought that she did not need to see a psychiatrist. For Items P8-10, Patient can have been under the influence of alcohol/drugs. Experienced trouble controlling violent behavior including episodes of rage, or violence? Client stated that she becomes violent when drinking only if her ex-husband calls her. She stated that this is worse after she has been drinking. Experienced serious thoughts of suicide? Patient seriously considered a plan for taking his/her life. Client was hospitalized on 12/2/2015 for suicidal threat/ideation and was held for three days before release. Client does not remember much about this incident. Client is not currently suicidal or homicidal. Attempted suicide? Client threatened to swallow pills on 12/2/2015 which resulted in involuntary hospitalization. Client reported that she has not felt suicidal since that incident. It should be noted that client was subsequently prescribed anti-depressants (though she cannot recall which ones) for a year. Psychiatric Status Comments When client described psychiatric treatment, her responses were vague. It sounds as if she did not see the psychiatrist more than a few times. Client reported that she only remembers meeting with him four or five times in the year that she saw him for medical management check-ups. She cannot recall which drugs she was prescribed. *NOTE* we have consent to contact the psychiatrist (see client file). Client spoke openly about her suicide threat. Prior to the threat, the client reported that she considered suicide for a month or so. When asked about the precipitating event, the client reported that her ex-husband called to make sure that she was home so that the divorce papers could be delivered. Client reported that she did not want the divorce. Client would not discuss the relationship further.

Date of Interview:
How long have you lived at this address Years:
Months:
Other:
How many days approximately:
Training or Technical education Area of specialization:
College completed Degree and major:
Years:
Months_2:
Usual or last occupation specify:
days:
How important to you now is counseling for these employment problems:
too 1:
too 2:
too 3:
of times in the last 30 days:
of times in the last 30 days_2:
of times in the last 30 days_3:
of times in the last 30 days_4:
of times in the last 30 days_5:
of times in the last 30 days_6:
of times in the last 30 days_7:
of times in the last 30 days_8:
of times in the last 30 days_9:
of times in the last 30 days_10:
of times in the last 30 days_11:
of times in the last 30 days_12:
Alcohol use:
Drug use:
Alcohol:
Drugs:
Alcohol_2:
Drugs_2:
30 days Include AANA:
How many days in the past 30 have you experienced alcohol problems:
How troubled or bothered have you been in the past 30 days by these alcohol problems:
How important to you now is treatment for these alcohol problems:
How many days in the past 30 have you experienced drug problems:
How troubled or bothered have you been in the past 30 days by these drug problems:
How important to you now is treatment for these drug problems:
Include any contradictions or important notes that relate to the clients substance use:
1:
2:
Are you on parole or probation Note duration and level in comments 1:
Are you on parole or probation Note duration and level in comments 2:
Are you on parole or probation Note duration and level in comments 3:
How many of these charges resulted in convictions:
pleas should be noted in comments area 1:
pleas should be noted in comments area 2:
pleas should be noted in comments area 3:
Include anything that the client stated that was important 1:
Include anything that the client stated that was important 2:
Include anything that the client stated that was important 3:
Include important information 1:
Include important information 2:
Include important information 3:
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