Domestic Violence Drug Alcohol Assessment - Affordable Counseling Educational Services

Drug and Alcohol Assessment

Initial Contact and Intake

Program Contract

Waiver of Confidentiality

Promise to Maintain Confidentiality

Program Policy

Drug and Alcohol Assessment

Number of arrests since age 18 wherein drugs and/or alcohol played a part or you were under the influence or had been using at the time of the arrest.

Yes No

Number of times arrested:

Number of arrests since age 18 that were drug and/or alcohol related regardless of whether you were under the influence.

Yes No

Number of times arrested:

a. i.e. Resisting and/or evading arrest, assault, vandalism, burglary, trespassing, terrorist threats, child abuse/i.e. Distribution, cultivating, intent to sale, paraphernalia, neglect/endangerment, unlawful detention, false imprisonment, break and entering, kidnapping, supplying a minor, etc.

What have you lost as a result of your addictions dependency, use, abuse of alcohol/drugs?

a. custody of children, visitation restrictions with children, freedom, job, marriage, long term relationships with friends, family members, partners. Money/credit, driver’s license, garnishment of wages, IRS bills, etc.

How many times a year do you believe you were legally too impaired to safely/legally operate a motor vehicle?

How many times in the past year have you had lapses or losses of time wherein you didn’t recall what occurred during that period of time (Hours, days, weeks)?

Do you consider yourself to be an alcoholic?

Yes No

Do you consider yourself to be a drug addict?

Yes No

How often do you attend AA, NA, Prop 36 or other treatment program meetings per week?