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ANTA Alcohol & Other

Drugs Toolbox
Sample Assessment
Form

Sample Assessment Form


(front page)

Case Summary:

Client’s Name:

Current Address:

Contact Telephone:

Age and Date of Birth: Gender:

Ethnic/cultural background:

Is an interpreter required?: If yes… what language………………………………………………

Does the client have children? (if yes provide details – ages, with whom do they live)

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Has client been referred by others or self?

Referral information and source:

Referral problem stated:

Description of general presenting problems and relevant AOD issues:

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Date interviewed:

Name and position of interviewer:

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Details of substance use
Specify Drug(s):

Age of first use:

Age of first regular use:

Route of administration:

Average daily use:

Number of days used in past seven days:

Number of days used in past four weeks:

Last use:

Period of time client has used daily:

Comments regarding substance use


For example, abuse, dependence, intoxication, withdrawal.

Details of prescribed medications


Specify medications:

Prescribed dose:

Taking medication as prescribed (if no state reason):

Duration of treatment:

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Reason for prescription:

Prescribing doctor/health practitioner:

Comments regarding prescribed medication


For example past history of prescribed medication.

Other drug use in the family

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Genogram
Sample genogram

An example of a family genogram is provided below.

o Female symbol

 Male symbol

∆ Unknown sex

___ Married

Client lives with those closed in circle

----- De facto relationship

/ Separation (add year if desired)

// Divorce (add year if desired)

 Death (of a male) add year if known


1990 1983

1990

1994 Client

Insert clients genogram:

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Medical/physical assessment
Current problems in need of immediate attention:

(Tick as appropriate)
Allergies Gastrontestinal Cardiac problems
 problems
 
Hepatitis C Seizures/fits/ Pregnancy
 epilepsy
 
Hepatitis B Respiratory (eg Chronic pain
 asthma)
 
HIV Diabetes Head injuries
  
Liver Disease Skeletal injuries
  
Dental Other (please specify)

Past relevant medical history

General hospital admissions (including number of GP/casualty attendances, ambulance trips.


Specify date, hospital, reasons for admission, length of stay)

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Medical history

Medication

Physical appearance

Physical state

Other comments (including impact of substance use on general health, weight loss, eating
pattern, nutrition)

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Social

Accommodation

Employment/Education

Finance

Social networks/Relationships

Legal history

Current legal problems

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Psychological/emotional

General appearance

Behaviour

Mood

Thought

Level of awareness

Previous psychiatric history (Include family history of mental


illness)

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Currently receiving treatment

Yes

No

Name :

Contact No:_

Suicide/self-harm risk assessment (tick applicable


items)

Sense of hopelessness/worthlessness

Ideation (do you ever think about killing/harming yourself?)*

Intent (do you want to kill/harm yourself?)

Plan (how would you do it?)

Lethality (is the method likely to be lethal?)

Accessibility?

Previous attempts?

Suicide/attempted suicide of significant other?

* If evidence of suicidal ideation, include it on the summary sheet

Comments

Is a full psychiatric assessment required? Yes/No

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If yes, the form ‘Current Mental State’ is to be completed by a psychiatrist,
psychologist or other appropriately qualified clinician. (see appendix 1)

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Other comments

Readiness to change

Client’s goals

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Individual Treatment Plan

Immediate plan

Medium

Long-term

Main goals to be addressed by client and care plan manager:

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Is client familiar with the agency conditions and contract?

Yes

No

If not, explain

Does the client know about their rights regarding confidentiality,


grievance procedures, etc.

Yes

No

If not, explain policy:

Any special needs or services required?

Yes

No

If so, specify:

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Specify services to be provided by your agency and other relevant
organisations:

Future contact date and time required:

Is action to be taken by either party before next appointment?

Specify by whom the action is to be taken?

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Appendix 1
Current Mental State Examination

NOTE – Current Mental State is to be completed by a psychiatrist, psychologist or other


qualified individual with psychiatric training.

Appearance
(eg physical presentation, conscious state)

Behaviour
(eg psychomotor activity, mannerisms, social appropriateness)

Conversation
(eg Form/coherence, flow, content/themes)

Thought Disorder
(eg delusions)

Perceptual disorder
(eg hallucinations/illusions)

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Mood

Intellectual functioning
(memory, attention, orientation, insight)

NOTE – If client demonstrates objective/subjective intellectual difficulties, and is at least five


days post-detox and is not currently drug-affected, you may consider administering the
cognitive status examination (CSE0 to determine if further cognitive assessment may be
warranted).

Comments

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