Review the Intake Assessment Form.

Create a fictional history of an inmate or offender who has an alcohol or substance abuse disorder to use for this assignment. 

APA 7th Edition: The Basics of APA In-text Citations | Scribbr ????

Here are examples of models:

– The Social Learning Model

– The Biopsychosocial Model

– The Community-Based Prevention Model

– The Harm Reduction Model

– The Trauma-Informed Care Model

Various models of substance abuse prevention, intervention, and rehabilitation are available for the delivery of support services for justice-involved individuals with addiction and substance abuse issues. It is important to understand how and when these various models can be applied to various diverse populations. Much information about a client’s situation can be obtained through intake interviews with the client. In this assignment, you will explore the types of information you can learn about your client through an intake interview, and discover how to apply substance abuse prevention, intervention, and rehabilitation models to such a situation.

Create a 1,200  word paper

Include An Introduction and Conclusion 

You should: 

  • Describe the inmate or offender with an alcohol or substance abuse disorder who is seeking treatment at your correctional facility (e.g., prison, jail, parole, probation, or diversion). 200 words
  • Describe this inmate or offender’s life experience through their initiation of substance use, prior treatment, and any periods of sobriety.  200 words
  • Describe and analyze at least 2 models of substance abuse prevention, intervention, and/or rehabilitation that could be used in the delivery of support services for this client. 200 words
  • Outline the treatment strategies you are proposing for the inmate or offender.  200 words
  • Identify 2 treatment goals you will work on with the inmate or offender.  200 words

Include 2 references. 

Format any citations in your presentation according to APA guidelines. 

CPSS/420 v2

Intake Assessment Form

CPSS/420 v2

Page 2 of 2

C:UsersdjshireyOneDrive - University of PhoenixF_DriveStyle GuidesUPX LogosHorizontal formatUOPX_Sig_Hor_Black_Medium.pngIntake Assessment Form

Intake Instructions

Intake staff shall review each completed intake assessment completed for each program participant. The intake assessment may help identify a program participant’s treatment needs, but it is the responsibility of staff to gather additional information in the following areas: Social supports, economic resources (including health insurance or Medicaid availability), the program participant’s family history, education, employment history, criminal history, legal status, medical history, alcohol use and other drug use history, and finally previous treatment programs.

Intake assessments should include the evaluation of substance use disorders; the evaluation of alcohol use disorders, and the assessment of treatment needs. This information is utilized to create client driven, clinically supported treatment plans that are SMART (Specific, Measurable, Attainable, Realist and Timelined)

Client Information

Client’s First Name:

Client’s Last Name:

Date of Birth:

Insurance Type:

Client’s Preferred Name:

Admission Date:

Emergency Contact Information

Emergency Contact:

Relationship:

Contact Address (Street, City, State, Zip):

Contact Phone Number:

Release for Emergency Contact obtained for this time period:

Personal Information

Sex Assigned at Birth

Mention ‘Yes’ against what is relevant:

Male:

Female:

Intersex:

Gender queer:

Gender non-conforming:

Male to female:

Female to male:

Other (Specify):

Unknown or declined to state:

Gender Identity

Mention ‘Yes’ against what is relevant:

Male:

Female:

Intersex:

Gender queer:

Gender non-conforming:

Male to female:

Female to male:

Other:

Unknown or declined to state:

Pronoun Preferred

Mention ‘Yes’ against what is relevant:

Him:

Her:

They:

Other:

Unknown:

Referral Reason

Why has the client been referred?

Treatment counselor:

Alcohol and Drug History

Fill in appropriate details for each.

Check if ever used:

Age at first use:

None or denies

Current Use

Current Abuse

Current Dependence

In Recovery

Client-perceived Problem? Write Y or N

Alcohol

Amphetamines (Speed/Uppers, etc.)

Cocaine/Crack

Opiates (Heroin, Oxy, Methadone, Suboxone)

Hallucinogens (LSD, Mushrooms, Ecstasy, Molly)

Sleeping pills, Benzos, Valium, or similar

PSP (Phencyclidine) or Designer Drugs (GHB)

Inhalants (paint, gas, glue, aerosols)

Marijuana, Hashish. DABS

Tobacco, nicotine, vaping, chew

Caffeine (energy drinks, sodas, coffee, etc.)

Over the counter

Other substances

Complimentary alternative medication

Previous Drug and/or Alcohol Treatment History:

Type of Previous Recovery Treatment (Inpatient, Outpatient, Residential,

Detoxification)

Name of Previous Treatment Facility

Dates of Previous Treatment

Treatment Completed (Yes or No)

Medical History:

Medical Provider

Name:

Phone #:

Last Date of Service:

Primary Physician:

Other medical provider(s)

Date records requested:

From whom, if applicable:

Relevant Medical History

General Info:

Baseline weight:

Weight changes:

BP:

Mention ‘Yes’ wherever relevant

Condition

Cardiovascular

Respiratory

Genital, urinary, bladder

Gastro-intestinal bowel

Nervous system

Musculoskeletal

Gyneco logy

Skin

Endocrine

Chest pain

Hypertension

Hypotension

Palpitation

Smoking

Bronchitis

Asthma

COPD

COVID

Incontinence

Nocturia

UTI

Retention

Urgency

Heartburn

Diarrhea

Constipation

Nausea

Vomiting

Ulcers

Pancreatitis

Headache

TBI/LOC

Seizures

Memory

Concentration

Back pain

Broken bones

Arthritis

Mobility issues

Pregnant

STD

Menopause

Scar

Lesion

Lice

Dermatitis

Burns

Diabetes

Thyroid

Significant accident

Injuries

Surgeries

Hospitalizations

Physical disability

Chronic illness

HIV

Liver disease

Write details against what is relevant:

Significant accident

Injuries:

Surgeries:

Hospitalizations:

Physical disability:

Chronic illness:

HIV:

Liver disease:

Alternative healing practice/date

For example, acupuncture, herbs, supplements, etc.

Date:

Provider/Type:

Reason for Treatment:

Outcome (Was it helpful and why)

Current/ Previous Medications

(Include all prescribed, OTC, holistic/alternative remedies)

Rx Name

Effectiveness Side Effects

Dosage

Date Started

Prescriber

Current

Past

Psychotropic or Nonpsychotropic

Allergies/Adverse Reactions/ Sensitivities:

Food:

Drugs (Rx/OTC/ILLICT):

Unknown:

Other:

Date of last physical exam:

Date of last dental exam:

Referral made to primary care or specialty (Yes or No. If yes, list):

1.

2.

3.

Additional Medical Information:

Mental Health History

Psychiatric Hospitalizations

Yes or No:

Outpatient Treatment

Yes or No:

Risk factors

Mention ‘Yes’ against what is relevant:

Aggressive/Violent Behaviors:

Self-Harm:

Client referred to crisis services line:

Mental health disorders that are pre-existing, contribute to substance use/abuse, or have been exacerbated by substance use:

Psychosocial History

Family problems that are contributing to, or are exacerbated by, substance abuse. Mention ‘Yes’ against what is relevant and describe below:

Arguments:

Domestic violence:

Family abuses alcohol/drugs:

Family worried about client’s use of drugs/alcohol:

Separated or divorced:

Describe Problems Contributing to Substance Abuse

Social problems that are contributing to, or are exacerbated by, substance abuse. Describe below and check severity:

Mild Y/N

Moderate Y/N

Severe Y/N

Describe economic problems that are contributing to, or are exacerbated by, substance use:

Mild Y/N

Moderate Y/N

Severe Y/N

Describe cultural factors which may influence presenting problems: (may include ethnicity, race religion, spiritual practice, sexual orientation, gender identity, socioeconomic status, living environment, etc.:

Mild Y/N

Moderate Y/N

Severe Y/N

Describe educational problems that are exacerbated by substance

abuse:

Mild

Moderate

Severe

Highest level of education completed:

Employment History

Client currently employed? (Yes/ No):

If so, list employer and job:

1.

2.

Problems Caused by Substance Abuse:

Add “Yes” after anything substance use/abuse has caused or contributed to:

Absenteeism:

Tardiness:

Accidents:

Working while hung-over:

Trouble concentrating:

Decreased job performance:

Consumed substances while at work:

Lost job due to substance abuse:

No work problem:

Comments:

Criminal History/Legal Status

Criminal History Table

Criminal justice history/violent incidents of individual and/or family:

Within last 90 days (Yes or No)

Past

(Yes or No)

Assault on persons (DV)

Threat to persons

Property damage

DUI

Legal Status Table

Legal history:

Within last 90 days (Yes or No)

Past

(Yes or No)

Probation

Parole

Adjudicated

Diversion

Other:

Describe criminal justice involvement.

Note: More space is provided in the Addendum

Date

Type of crime

Outcome

Other

Describe any relevant family involvement with criminal justice.

Note: More space is provided in the Addendum

Date

Relation to client

Type of crime

Outcome

Other

Personal History

Write ‘Not Applicable’ if not applicable.

Client currently in a relationship? If yes, list length or other comments below:

History of sexual abuse?

History of physical abuse?

Does client have children? If yes, list age of each below:

Child 1:

Child 2:

Child 3:

Child 4:

Child 5:

Describe assessed knowledge of parenting skills.

Describe assessed education/knowledge of harmful effects that alcohol and drugs have on the caregiver and fetus, or caregiver and infant.

List parenting skills most needed.

Does client need or will client receive childcare? Answer yes or no:

Client needs to access the following ancillary services which are medically necessary. Provide comments below: (Mention ‘Yes’ against what is relevant)

Dental services:

Social services:

Community services:

Educational/Vocational training:

Transportation (or arranging for) to and from medically necessary treatment:

Other: Specify:

Clinical Formulation

Instructions: Consider all information gathered in the intake assessment for the treatment plan formulation. The formulation should identify each problem that is contributing to client’s alcohol or substance use disorder. All issues identified during the intake assessment process must be listed as a problem statement on the treatment plan (SMART goals). However, some problem statements can de deferred as determined appropriate by the treatment staff.

Addendum

Use this area to report additional criminal justice involvement, etc.

Copyright 2021 by University of Phoenix. All rights reserved.

Copyright 2021 by University of Phoenix. All rights reserved.

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