Week 3 assignment capstone 3

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ata Analysis

View the videos “Reverse Scored Items and Subscales” and “Subscale Scoring” for examples of how to compute reverse-scored items and subscales.

Complete all of the steps necessary to prepare your data for analysis.  Make sure each of the following steps has been completed:

1  All reverse-scored items have been computed in a separate variable.  Label all reverse-scored variables with the name of the original variable followed by R. (for example, CCI4 would be reverse-scored into a new variable, CCI4R).

2  All subscales have been totalled.  Create a new variable for each subscale and label all subscales with names that can be clearly identified.

3  A total score has been calculated for each assessment instrument (if appropriate).

Submit the SPSS database containing all original data as well as the variables listed above.  Also attach a separate Word document containing a list of the variables that have been added or modified.  For example, list each reverse scored item along with the variable names of the original and reverse-scored variables.  Also list the variable names of the subscales and indicate which items were included in each subscale.

Also attach the instruments that are being used for each program. If you are not able to obtain an actual instrument, provide a description of the instrument that explains the items, including the measurement scale.  Attach the scoring instructions for each instrument.  Provide a full reference for each instrument used in each of the two programs

NovoPsych

Spence Children’s Anxiety Scale – Child (SCAS-
Child)

Instructions:
Please tap to button to show how often each of these things happen to you. There are no
right or wrong answers.

Never Sometimes Often Always

1 I worry about things 0 1 2 3

2 I am scared of the dark 0 1 2 3

3
When I have a problem, I get a
funny feeling in my stomach

0 1 2 3

4 I feel afraid 0 1 2 3

5
I would feel afraid of being on my
own at home

0 1 2 3

6
I feel scared when I have to take a
test

0 1 2 3

7
I feel afraid if I have to use public
toilets or bathrooms

0 1 2 3

8
I worry about being away from my
parents

0 1 2 3

9
I feel afraid that I will make a fool of
myself in front of people

0 1 2 3

10
I worry that I will do badly at my
school work

0 1 2 3

11
I am popular amongst other kids my
own age

0 1 2 3

12
I worry that something awful will
happen to someone in my family

0 1 2 3

13
I suddenly feel as if I can’t breathe
when there is no reason for this

0 1 2 3

14
I have to keep checking that I have done
things right (like the switch is off, or the
door is locked)

0 1 2 3

15
I feel scared if I have to sleep on my
own

0 1 2 3

16
I have trouble going to school in the
mornings because I feel nervous or
afraid

0 1 2 3

Page 1 of 3

NovoPsych

Never Sometimes Often Always

17 I am good at sports 0 1 2 3

18 I am scared of dogs 0 1 2 3

19
I can’t seem to get bad or silly
thoughts out of my head

0 1 2 3

20
When I have a problem, my heart
beats really fast

0 1 2 3

21
I suddenly start to tremble or shake
when there is no reason for this

0 1 2 3

22
I worry that something bad will
happen to me

0 1 2 3

23
I am scared of going to the doctors
or dentists

0 1 2 3

24 When I have a problem, I feel shaky 0 1 2 3

25
I am scared of being in high places
or lifts (elevators)

0 1 2 3

26 I am a good person 0 1 2 3

27
I have to think of special thoughts to stop
bad things from happening (like numbers
or words)

0 1 2 3

28
I feel scared if I have to travel in the
car, or on a Bus or a train

0 1 2 3

29
I worry what other people think of
me

0 1 2 3

30
I am afraid of being in crowded places
(like shopping centres, the movies,
buses, busy playgrounds)

0 1 2 3

31 I feel happy 0 1 2 3

32
All of a sudden I feel really scared
for no reason at all

0 1 2 3

33 I am scared of insects or spiders 0 1 2 3

34
I suddenly become dizzy or faint
when there is no reason for this

0 1 2 3

35
I feel afraid if I have to talk in front of
my class

0 1 2 3

36
My heart suddenly starts to beat too
quickly for no reason

0 1 2 3

Page 2 of 3

NovoPsych

Never Sometimes Often Always

37
I worry that I will suddenly get a scared
feeling when there is nothing to be afraid
of

0 1 2 3

38 I like myself 0 1 2 3

39
I am afraid of being in small closed
places, like tunnels or small rooms

0 1 2 3

40
I have to do some things over and over
again (like washing my hands, cleaning
or putting things in a certain order)

0 1 2 3

41
I get bothered by bad or silly
thoughts or pictures in my mind

0 1 2 3

42
I have to do some things in just the right
way to stop bad things
happening

0 1 2 3

43 I am proud of my school work 0 1 2 3

44
I would feel scared if I had to stay
away from home overnight

0 1 2 3

45 Is there something else that you are really afraid of?

0 Yes

0 No

46 If you are afraid of something else please write down what it is. How often are you afraid of this thing?

Developer Reference:
Spence, S.H. (1997). Structure of anxiety symptoms among children: A confirmatory factor-
analytic study. Journal of Abnormal Psychology, 106(2), 280-297.

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Page 3 of 3

A. Thomas McLellan, Ph.D.
Deni Carise, Ph.D.

Thomas H. Coyne, MSW
T. Ron Jackson, MSW

Remember: This is an interview, not a test

≈Item numbers circled are to be asked at follow-up.≈
≈Items with an asterisk * are cumulative and should be rephrased at

INTRODUCING THE ASI: Introduce and explain the seven potential
problem areas: Medical, Employment/Support Status, Alcohol, Drug,
Legal, Family/Social, and Psychiatric. All clients receive this same
standard interview. All information gathered is confidential; explain what
that means in your facility; who has access to the information and the
process for the release of information.
There are two time periods we will discuss:
1. The past 30 days
2. Lifetime

Patient Rating Scale: Patient input is important. For each area, I will ask
you to use this scale to let me know how bothered you have been by any
problems in each section. I will also ask you how important treatment is
for you for the area being discussed.
The scale is: 0 – Not at all
1 – Slightly
2 – Moderately
3 – Considerably
4 – Extremely
Inform the client that he/she has the right to refuse to answer any question.
If the client is uncomfortable or feels it is too personal or painful to give an
answer, instruct the client not to answer. Explain the benefits and
advantages of answering as many questions as possible in terms of
developing a comprehensive and effective treatment plan to help them.

Please try not give inaccurate information!

INTERVIEWER INSTRUCTIONS:
1. Leave no blanks.
2. Make plenty of Comments (if another person reads this ASI, they

should have a relatively complete picture of the client’s perceptions of
his/her problems).

3. -9 = Question not answered.
-8 = Question not applicable.

4. Terminate interview if client misrepresents two or more sections.
5. When noting comments, please write the question number.

HALF TIME RULE: If a question asks the number of months,
round up periods of 14 days or more to 1
month. Round up 6 months or more to 1
year.

CONFIDENCE RATINGS:⇒ Last two items in each section.
⇒ Do not over-interpret.
⇒ Denial does not warrant
misrepresentation.
⇒ Misrepresentation = overt contradiction in
information.

Probe, cross-check and make plenty of comments!

HOLLINGSHEAD CATEGORIES:
1. Higher execs, major professionals, owners of large businesses.
2. Business managers if medium sized businesses, lesser professions, i.e.,

nurses, opticians, pharmacists, social workers, teachers.
3. Administrative personnel, managers, minor professionals, owners/

proprietors of small businesses, i.e., bakery, car dealership, engraving
business, plumbing business, florist, decorator, actor, reporter, travel
agent.

4. Clerical and sales, technicians, small businesses (bank teller,
bookkeeper, clerk, draftsperson, timekeeper, secretary).

5. Skilled manual – usually having had training (baker, barber,
brakeperson, chef, electrician, fireman, machinist, mechanic,
paperhanger, painter, repairperson, tailor, welder, police, plumber).

6. Semi-skilled (hospital aide, painter, bartender, bus driver, cutter, cook,
drill press, garage guard, checker, waiter, spot welder, machine
operator).

7. Unskilled (attendant, janitor, construction helper, unspecified labor,
porter, including unemployed).

ALCOHOL/DRUG USE INSTRUCTIONS:
The following questions refer to two time periods: the past 30 days and lifetime.
Lifetime refers to the time prior to the last 30 days.
⇒ 30 day questions only require the number of days used.
⇒ Lifetime use is asked to determine extended periods of use.
⇒ Regular use = 3+ times per week, binges, or problematic irregular
use in which normal activities are compromised.
⇒ Alcohol to intoxication does not necessarily mean “drunk”, use the
words “to feel or felt the effects”, “got a buzz”, “high”, etc. instead
of intoxication. As a rule of thumb, 3+ drinks in one sitting, or 5+
drinks in one day defines “intoxication”.
⇒ How to ask these questions:
→ “How many days in the past 30 have you used….?”
→ “How many years in your life have you regularly used….?”

{Module Name} Module

Addiction Severity Index – 5th Edition
Clinical/Training Version

LIST OF COMMONLY USED DRUGS:
Alcohol: Beer, wine, liquor
Methadone: Dolophine, LAAM
Opiates: Pain killers = Morphine, Diluaudid, Demerol,
Percocet, Darvon, Talwin, Codeine, Tylenol 2,3,4,
Robitussin, Fentanyl
Barbiturates: Nembutal, Seconal, Tuinol, Amytal, Pentobarbital,
Secobarbital, Phenobarbital, Fiorinol
Sed/Hyp/Tranq: Benzodiazepines = Valium, Librium, Ativan, Serax
Tranxene, Xanax, Miltown,
Other = ChloralHydrate (Noctex), Quaaludes
Dalmane, Halcion
Cocaine: Cocaine Crystal, Free-Base Cocaine or “Crack,” and
“Rock Cocaine”
Amphetamines: Monster, Crank, Benzedrine, Dexedrine, Ritalin,
Preludin, Methamphetamine, Speed, Ice, Crystal
Cannabis: Marijuana, Hashish
Hallucinogens: LSD (Acid), Mescaline, Mushrooms (Psilocybin), Peyote,
Green, PCP (Phencyclidine), Angel Dust, Ecstacy
Inhalants: Nitrous Oxide, Amyl Nitrate (Whippits, Poppers),
Glue, Solvents, Gasoline, Toluene, Etc.

Just note if these are used: Antidepressants,
Ulcer Meds = Zantac, Tagamet
Asthma Meds = Ventoline Inhaler, Theodur
Other Meds = Antipsychotics, Lithium

{Module Name} Module

Addiction Severity Index – 5th Edition
Clinical/Training Version

Agency Name: ___________________________ Site Name: ______________________________

ID #: __ __ __ __ __ __ Date: __ __ / __ __ / __ __ __ __

GENERAL INFORMATION COMMENTS
(Include the question number with your notes)

______________________________________________________

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GENERAL INFORMATION
G1. ID Number __________________________
G4. Date of Admission

mm/dd/yyyy
__ __ /__ __ /__ __ __ __

G5. Date of Interview

mm/dd/yyyy
__ __ /__ __ /__ __ __ __

G6. Time Begun

Use 24 hr clock; code hours:minutes
___ ___ : ___ ___

G7. Time Ended
Use 24 hr clock; code hours:minutes

___ ___ : ___ ___
HRS MINS

G8. Class
1 – Intake 2 – Follow-up

___

G9. Contact Code ___
1 – In person 2 – Telephone (Intake ASI must be in person)

G10. Gender
1 – Male 2 – Female

___

G99. Treatment Episode Number ___ ___

G11. Interviewer Code Number ___ ___ ___

G12. Special
1 – Patient terminated
2 – Patient refused
3 – Patient unable to respond

___

G14. How long have you lived at your current
address?

__ __ / __ __
YRS MOS

G15. Is this residence owned by you or your family?
0 – No 1 – Yes

___

G16. Date of birth __ __ /__ __ /__ __ __ __
mm/dd/yyyy

G17 Of what race do you consider yourself? ___
1 – White (not Hisp) 5 – Asian/Pacific
2 – Black (not Hisp) 6 – Hispanic-Mexican
3 – American Indian 7 – Hispanic-Puerto Rican
4 – Alaskan Native 8 – Hispanic-Cuban
9 – Unknown
G18. Do you have a religious preference? ___
1 – Protestant 4 – Islamic
2 – Catholic 5 – Other
3 – Jewish 6 – None
G19. Have you been in a controlled environment in

the past 30 days?
___

1 – No 4 – Medical tx
2 – Jail/prison 5 – Psychiatric tx
3 – Alcohol or drug tx 6 – Other
A place, theoretically, without access to drugs/alcohol.
G20. How many days? ___ ___

If G19 is No, code -8.
Refers to total number of days detained in the past 30 days.

MEDICAL STATUS

M1. *

How many times in your life have you been
hospitalized for medical problems? ___ ___

Include O.D.’s and D.T.’s. Exclude detox, alcohol/drug, psychiatric treatment
and childbirth (if no complications). Enter the number of overnight
hospitalizations for medical problems.

M2. How long ago was your last hospitalization for __ __ / __ __
a physical problem? YRS MOS
If no hospitalizations in Question M1, then code -8 / -8.

MEDICAL COMMENTS
(Include the question number with your notes)

______________________________________________________

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INTERVIEWER SEVERITY RATING
M9. How would you rate the patient’s need for medical

treatment?
Refers to the patient’s need for additional medical treatment.

___

M4. Are you taking any prescribed medication on a
regular basis for a physical problem?
0 – No 1 – Yes

___

If Yes, specify in comments.
Medication prescribed by a MD for medical conditions; not psychiatric
medicines. Include medicines prescribed whether or not the patient is currently
taking them. The intent is to verify chronic medical problems.

M5. Do you receive a pension for a physical disability?
0 – No 1 – Yes ___

If Yes, specify in comments.
Include Workers’ compensation, exclude psychiatric disability.

M6. How many days have you experienced medical
problems in the past 30 days? ___ ___

Include flu, colds, etc. Include serious ailments related to drugs/alcohol, which
would continue even if the patient were abstinent (e.g., cirrhosis of liver,
abscesses from needles, etc.).

For Questions M7 & M8, ask patient to use the Patient Rating Scale
M7. How troubled or bothered have you been by these

medical problems in the past 30 days?
Restrict response to problem days in Question M6.

___

M8. How important to you now is treatment for these medical
problems?
If client is currently receiving medical treatment, refer to the need for
additional medical treatment by the patient.

___

CONFIDENCE RATINGS
Is the above information significantly distorted by:

M10. Patient’s misrepresentation?
0 – No 1 – Yes

___

M11. Patient’s inability to understand?
0 – No 1 – Yes

___

M3. Do you have any chronic medical problems which
continue to interfere with your life?
0 – No 1 – Yes

___

If Yes, specify in comments.
A chronic medical condition is a serious physical condition that requires regular
care (i.e., medication, dietary restriction) preventing full advantage of their
abilities.

EMPLOYMENT/SUPPORT STATUS

E1. * Education completed
GED = 12 years, note in comments.
Include formal education only.

__ __ / __ __
YRS MOS

EMPLOYMENT/SUPPORT COMMENTS
(Include the question number with your notes)

______________________________________________________

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E2. * Training or technical education completed
Formal, organized training only. For military training, only
include training that can be used in civilian life (i.e., electronics,
computers).

__ __
MOS

E3. Do you have a profession, trade, or skill?
0 – No 1 – Yes ___

Employable, transferable skill acquired through training.
If Yes, specify: __________________________________

E6. How long was your longest full-time job?
Full-time = 35+ hours weekly; does not necessarily mean
most recent job.

__ __ / __ __
YRS MOS

E10. Usual employment pattern, past 3 years? ___
1 – Full time (35+ hours) 5 – Military service
2 – Part time (regular hours) 6 – Retired/disability
3 – Part time (irregular hours) 7 – Unemployed
4 – Student 8 – In controlled environment
Answer should represent the majority of the last 3 years, not just the most

recent selection. If there are equal times for more than one category, select
that which best represents the current situation.

E4. Do you have a valid driver’s license?
0 – No 1 – Yes ___

Valid license; not suspended/revoked.

E5. Do you have an automobile available for use?
0 – No 1 – Yes

___

If answer to E4 is No, then E5 must be No.
Does not require ownership, only requires availability on a regular basis.

E7. * Usual (or last) occupation ___
Specify
Use Hollingshead Categories Reference Sheet

E11. How many days were you paid for working in the
past 30 days? ___ ___

Include “under-the-table” work, paid sick days and vacation.

E8. Does someone contribute to your support in any way?
0 – No 1 – Yes

___

Is patient receiving any regular support (i.e., cash, food, housing) from family/
friend. Include spouse’s contribution; exclude support by an institution.

E9. Does this support constitute the majority of your
support?
0 – No 1 – Yes

___

If E8 is No, then E9 is -8.

EMPLOYMENT/SUPPORT COMMENTS
(Include the question number with your notes)

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INTERVIEWER SEVERITY RATING
E22. ___ How would you rate the patient’s need for

employment counseling?

EMPLOYMENT/SUPPORT STATUS (cont)
For questions E12-E17:

How much money did you receive from the following sources in
the past 30 days?

E12. Employment
Net or “take home” pay, include any “under the
table” money.

$___ ___,___ ___ ___

E13. Unemployment compensation $___ ___,___ ___ ___
E14. Welfare

Include food stamps, transportation money
provided by an agency to go to and from treatment.

$___ ___,___ ___ ___

E15. Pension, benefits or social security
Include disability, pensions, retirement, veteran’s
benefits, SSI & workers’ compensation.

$___ ___,___ ___ ___

E16. Mate, family or friends
Money for personal expenses (i.e., clothing);
include unreliable sources of income.
Record cash payments only, include windfalls
(unexpected), money from loans, legal gambling,
inheritance, tax returns, etc.

$___ ___,___ ___ ___

E17. Illegal
Cash obtained from drug dealing, stealing, fencing
stolen goods, illegal gambling, prostitution, etc.
Do not attempt to convert drugs exchanged to a
dollar value.

$___ ___,___ ___ ___

E18. How many people depend on you for the majority
of their food, shelter, etc.? ___ ___

Must be regularly depending on patient; do include alimony/child support, do not
include the patient or self-supporting spouse, etc.

E19. How many days have you experienced employment
problems in the past 30? ___ ___

Include inability to find work, if they are actively looking for work, or problems
with present job in which that job is jeopardized.

For Questions E20 & E21, ask patient to use the Patient Rating Scale
E20. How troubled or bothered have you been by these

employment problems in the past 30 days?
If the patient has been incarcerated or detained during the past
30 days, they cannot have employment problems. In that case,
code -8.

___

E21. How important to you now is counseling for these
employment problems?
Stress help in finding or preparing a job, not giving them a job.

___

CONFIDENCE RATINGS
Is the above information significantly distorted by:
E23. Client’s misrepresentation?

0 – No 1 – Yes
___

E24. Client’s inability to understand?
0 – No 1 – Yes

___

ALCOHOL/DRUGS
Route of Administration Types:

1 – Oral 2 – Nasal 3 – Smoking 4 – Non-IV injection 5 – IV
Note the usual or most recent route. For more than one route, choose the most

severe. The routes are listed from least severe to most severe.
A.

Past 30
Days

B.
Lifetime
(Years)

C.
Route of
Admin

D1. Alcohol (any use at all) ___ ___ ___ ___

D2. Alcohol (to intoxication) ___ ___ ___ ___

D3. Heroin ___ ___ ___ ___ ___

D4. Methadone ___ ___ ___ ___ ___

D5. Other Opiates/Analgesics ___ ___ ___ ___ ___

D6. Barbiturates ___ ___ ___ ___ ___

D7.

Other Sedatives/Hypnotics/
Tranquilizers

___ ___ ___ ___ ___

D8. Cocaine ___ ___ ___ ___ ___

D9. Amphetamines ___ ___ ___ ___ ___

D10. Cannabis ___ ___ ___ ___ ___

D11. Hallucinogens ___ ___ ___ ___ ___

D12. Inhalants ___ ___ ___ ___ ___

D13.

More than one substance per day
Including alcohol

___ ___ ___ ___

D15. How long was your last period of voluntary
abstinence from this major substance?

___ ___
MOS

Last attempt of at least one month, not necessarily the longest. Periods of
hospitalization/incarceration do not count. Periods of antabuse, methadone,
or naltrexone use during abstinence do count.
00 = never abstinent

D16. How many months ago did this abstinence end?
If D15 = 0, then D16 = -8, 00 = Still abstinent

___ ___
MOS

ALCOHOL/DRUGS COMMENTS
(Include the question number with your notes)

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D14.
___ ___

According to the interviewer, which substance is/are
the major problem?
Interviewer should determine the major drug or drugs of abuse.
Code the number next to the drug in questions D1-D12, or:
00 = no problem
15 = alcohol & one or more drugs
16 = more than one drugs but no alcohol.
Ask patient when not clear.

ALCOHOL/DRUG COMMENTS
(Include the question number with your notes)

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INTERVIEWER SEVERITY RATING
How would you rate the patient’s need for treatment for:
D32. Alcohol problems ___

D33. Drug problems ___

How many times in your life have you been treated for:

D19.* Alcohol abuse? ___ ___

D20.* Drug abuse? ___ ___
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?

D21.* Alcohol?
If D19 = 0, then D21 = -8

___ ___

D22.* Drugs?
If D20 = 0, then D22 = -8

___ ___

How much money would you say you spent during the past 30
days on:

D23. Alcohol? $___ ___,___ ___ ___
D24. Drugs? $___ ___,___ ___ ___
Only count actual money spent. What is the financial burden caused by

drugs/alcohol?

D25. How many days have you been treated in an
outpatient setting for alcohol or drugs in the past
30 days?
Include AA/NA

___ ___

How many days in the past 30 have you experienced:
D26. Alcohol problems? ___ ___

D27. Drug problems? ___ ___
Include craving, withdrawal symptoms, disturbing effects of use, or wanting to

stop and being unable to.

For Questions D28 – D31, ask patient to use the Patient Rating Scale
How troubled or bothered have you been in the past 30 days by

these:
D28. Alcohol problems ___

D29. Drug problems ___

How important to you now is treatment for these:
D30. Alcohol problems ___

D31. Drug problems ___

CONFIDENCE RATINGS
Is the above information significantly distorted by:
D34. Client’s misrepresentation?

0 – No 1 – Yes
___

D35. Client’s inability to understand?
0 – No 1 – Yes

___

D17.* How many times have you had Alcohol D.T.’s?
Delirium Tremems (DTs): Occur 24-48 hours after last drink,
or significant decrease in alcohol intake, shaking, severe
disorientation, fever, hallucinations, they usually require
medical attention.

___ ___

D18.* How many times have you overdosed on drugs?
Overdoses (OD): Require requires intervention by someone
to recover, not simply sleeping it off, include suicide attempts
by OD.

___ ___

ALCOHOL/DRUGS (cont)

How many times in your life have you been arrested and
charged with the following?

L3. * Shoplifting/Vandalism ___ ___
L4. * Parole/Probation Violations ___ ___
L5. * Drug Charges ___ ___
L6. * Forgery ___ ___
L7. * Weapons Offense ___ ___
L8. * Burglary/Larceny/Breaking & Entering ___ ___
L9. * Robbery ___ ___
L10. * Assault ___ ___
L11. * Arson ___ ___
L12. * Rape ___ ___
L13. * Homicide/Manslaughter ___ ___
L14. * Prostitution ___ ___
L15. * Contempt of Court ___ ___
L16. * Other: ___________________________________ ___ ___
Include total number of counts, not just convictions.

Do not include juvenile (pre-age 18) crimes, unless they were tried as an adult.
Include formal charges only.

L17.* How many of these charges resulted in convictions? ___ ___
If L3-16 = 00, then Question L17 = -8.

Do not include misdemeanor offenses from questions L18-20 below.
Convictions include fines, probation, incarcerations, suspended sentences,
guilty please, and plea bargaining.

LEGAL STATUS
L1. Was this admission prompted or suggested by the

criminal justice system?
0 – No 1 – Yes

___

Judge, probation/parole officer, etc.

LEGAL COMMENTS
(Include the question number with your notes)

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L2. Are you on probation or parole?
0 – No 1 – Yes ___

Note duration and level in comments.

How many times in your life have you been charged with the
following:

L18. * Disorderly conduct, vagrancy, public intoxication ___ ___

L19. * Driving while intoxicated ___ ___
L20. * Major driving violations

Moving violations: speeding, reckless driving, no license, etc.
___ ___

L21. * How many months were you incarcerated in your
life?
If incarcerated 2 weeks or more, round this up to 1 month.
List total number of months incarcerated.

___ ___
MOS

L22. How long was your last incarceration?
Of 2 weeks or more. Code -8 if never incarcerated.

___ ___
MOS

L23. What was it for?
Use codes 03–16, 18–20
If multiple charges, code most severe.Code -8 if never
incarcerated.

___ ___

L24. Are you presently awaiting charges, trial, or sentence?
0 – No 1 – Yes ___

L25. What for? ___ ___
Refers to Question L24. Use the number of the type of crime
committed: 03-16 and 18-20. If multiple charges, code most severe.

LEGAL COMMENTS
(Include the question number with your notes)

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INTERVIEWER SEVERITY RATING
L30. How would you rate the patient’s need for legal

services or counseling?
___

L26. How many days in the past 30 were you detained or
incarcerated?
Include being arrested and released on the same day.

___ ___

LEGAL STATUS (cont)

L27. How many days in the past 30 have you engaged in
illegal activities for profit? ___ ___

Exclude simple drug possession. Include drug dealing,
prostitution, selling stolen goods, etc. May be cross-checked
with E17 under Employment section.

For Questions L28 & L29, ask patient to use the Patient Rating Scale
L28. How serious do you feel your present legal problems

are?
Exclude civil problems.

___

L29. How important to you now is counseling or referral
for these legal problems?
Patient is rating a need for additional referral to legal counsel for
defense against criminal charges.

___

CONFIDENCE RATINGS
Is the above information significantly distorted by:
L31. Client’s misrepresentation?

0 – No 1 – Yes
___

L32. Client’s inability to understand?
0 – No 1 – Yes

___

FAMILY HISTORY COMMENTS
(Include the question number with your notes)

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FAMILY HISTORY
Have any of your blood-related relatives had what you would call a significant drinking, drug use or psychiatric problem?

Specifically, was there a problem that did or should have led to treatment?
0 – Clearly NO for all relatives in the category
1 – Clearly YES for any relative within category
-9 – Uncertain or don’t know
-8 – Never was a relative

In cases where there is more than one person for a category, record the occurrence of problems for any in that group.
Accept the patient’s judgment on these questions.

Mother’s Side Alc Drug Psych Father’s Side Alc Drug Psych Siblings Alc Drug Psych

H1. Grandmother ___ ___ ___ H6. Grandmother ___ ___ ___ H11. Brother ___ ___ ___

H2. Grandfather ___ ___ ___ H7. Grandfather ___ ___ ___ H12. Sister ___ ___ ___

H3. Mother ___ ___ ___ H8. Father ___ ___ ___

H4. Aunt ___ ___ ___ H9. Aunt ___ ___ ___

H5. Uncle ___ ___ ___ H10. Uncle ___ ___ ___

FAMILY/SOCIAL RELATIONSHIPS
F1. Marital Status ___
1 – Married 4 – Separated
2 – Remarried 5 – Divorced
3 – Widowed 6 – Never married
Common-law marriage = 1. Specify in comments.

F2. How long have you been in this marital status?
Refers to F1. If never married, then since age 18.

__ __ / __ __
YRS MOS

F3. Are you satisfied with this situation?
0 – No 1 – Indifferent 2 – Yes
Satisfied=client generally liking the situation.
Refers to F1 and F2.

___

FAMILY/SOCIAL COMMENTS
(Include the question number with your notes)

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F4. * Usual living arrangements (past 3 years) ___
1 – With sexual partner & children 6 – With friends
2 – With sexual partner alone 7 – Alone
3 – With children alone 8 – Controlled environment
4 – With parents 9 – No stable arrangement
5 – With family
Choose arrangements most representative of the past 3 years. If there is an

even split in time between these arrangements, choose the most recent
arrangement.

F5. How long have you lived in these arrangements?
If with parents or family, since age 18.
Code years and months living in arrangements from F4.

__ __ / __ __
YRS MOS

F6. Are you satisfied with these arrangements?
0 – No 1 – Indifferent 2 – Yes

___

Do you live with anyone who:
F7. Has a current alcohol problem? 0 – No 1 – Yes ___

F8. Uses non-prescribed drugs? 0 – No 1 – Yes
Or abuses prescribed drugs

___

Would you say you have had a close reciprocal relationship
with any of the following people:

F12. Mother ___

F13. Father ___

F14. Brothers/Sisters ___

F15. Sexual Partner/Spouse ___

F16. Children ___

F17. Friends ___
0 – Clearly NO for all in class -9 – Uncertain or “I don’t know”
1 – Clearly YES for any in class -8 – Never was a relative
By reciprocal, you mean “that you would do anything you could to help them

out and vice versa.”

F9. With whom do you spend most of your free time?
1 – Family 2 – Friends 3 – Alone ___

If a girlfriend/boyfriend is considered as family by patient, then they must refer
to them as family throughout this section, not a friend.

F10. Are you satisfied with spending your free time this
way?
0 – No 1 – Indifferent 2 – Yes

___

A satisfied response must indicate that the person generally likes the situation.
Refers to F9.

F11. How many close friends do you have?
Stress that you mean close.
Exclude family members.
These are “reciprocal” relationships or mutually supportive
relationships.

___

FAMILY/SOCIAL COMMENTS
(Include the question number with your notes)

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Has anyone ever abused you?
0 – No 1 – Yes Past 30 Days In Your Life
F27. Emotionally?

Make you feel bad through harsh words
___ ___

F28. Physically?
Caused you physical harm

___ ___

F29. Sexually?
Force sexual advances/acts

___ ___

INTERVIEWER SEVERITY RATING
F36. How would you rate the patient’s need for family and/

or social counseling?
___

FAMILY/SOCIAL RELATIONSHIPS (cont)
Have you had significant periods in which you have experienced

serious problems getting along with:
0 – No 1 – Yes Past 30 Days In Your Life
F18. Mother ___ ___

F19. Father ___ ___

F20. Brothers/Sisters ___ ___

F21. Sexual Partner/Spouse ___ ___

F22. Children ___ ___

F23. Other significant family ___ ___
Specify: _______________________

F24. Close Friends ___ ___

F25. Neighbors ___ ___

F26. Co-Workers ___ ___
“Serious problems” mean those that endangered the relationship.

A “problem” requires contact of some sort, either by telephone or in person.
If no contact, code -8.

How many days in the past 30 have you had serious conflicts:

F30. With your family? ___ ___

F31. With other people? (excluding family) ___ ___

For Questions F32 – F35, ask patient to use the Patient Rating Scale

How troubled or bothered have you been in the past 30 days by:
F32. Family problems ___

F33. Social problems ___

How important to you now is treatment or counseling for these:
F34. Family problems

Patient is rating his/her need for counseling for family problems,
not whether they would be willing to attend.

___

F35. Social problems
Include patient’s need to seek treatment for such social problems
as loneliness, inability to socialize, and dissatisfaction with friends.
Patient rating should refer to dissatisfaction, conflicts, or other
serious problems.

___

CONFIDENCE RATINGS
Is the above information significantly distorted by:
F37. Client’s misrepresentation?

0 – No 1 – Yes
___

F38. Client’s inability to understand?
0 – No 1 – Yes

___

PSYCHIATRIC STATUS COMMENTS
(Include the question number with your notes)

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PSYCHIATRIC STATUS
How many times have you been treated for any psychological or

emotional problems:
P1. * In a hospital or inpatient setting? ___ ___

P2. * Outpatient/private patient? ___ ___
Do not include substance abuse, employment, or family counseling. Treatment

episode = a series of more or less continuous visits or treatment days, not the
number of visits or treatment days.
Enter diagnosis in comments if known.

P3. Do you receive a pension for a psychiatric disability?
0 – No 1 – Yes ___

P12. How many days in the past 30 have you experienced
these psychological or emotional problems?
Refers to problems noted in Questions P4-P10.

___ ___

For Questions P13 & P14, ask the patient to use the Patient Rating Scale

P13. How much have you been troubled or bothered by
these psychological or emotional problems in the
past 30 days?
Patient should be rating the problem days from Question P12.

___

P14. How important to you now is treatment for these
psychological problems?

___

Have you had a significant period of time (that was not a direct
result of drug/alcohol use) in which you have:

0 – No 1 – Yes Past 30 Days In Your Life
P4. Experienced serious depression

Sadness, hopelessness, loss of interest,
difficulty with daily functioning

___ ___

P5. Experienced serious anxiety or tension
Uptight, unreasonably worried, inability to
feel relaxed

___ ___

P6. Experienced hallucinations
Saw things/heard voices that others didn’t
see/hear

___ ___

P7. Experienced trouble understanding,
concentrating or remembering ___ ___

P8. Experienced trouble controlling violent
behavior including episodes or rage or
violence
Patient can be under the influence of alcohol/drugs.

___ ___

P9. Experienced serious thoughts of suicide
Patient seriously considered a plan for taking his/
her life.
Patient can be under the influence of alcohol/drugs.

___ ___

P10. Attempted suicide
Include actual suicidal gestures or attempts.
Patient can be under the influence of alcohol /
drugs.

___ ___

P11. Been prescribed medication for any
psychological or emotional problems
Prescribed for the patient by a physician. Record
“Yes” if a medication was prescribed even if the
patient is not taking it.

___ ___

PSYCHIATRIC STATUS COMMENTS
(Include the question number with your notes)

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INTERVIEWER SEVERITY RATING
P21. How would you rate the patient’s need for psychiatric/

psychological treatment?
___

The following items are to be completed by the interviewer:

At the time of the interview, the patient was: 0 – No 1 – Yes

P15. Obviously depressed/withdrawn ___

P16. Obviously hostile ___

P17. Obviously anxious/nervous ___

P18. Having trouble with reality testing, thought disorders,
paranoid thinking ___

P19. Having trouble comprehending, concentrating,
remembering ___

P20. Having suicidal thoughts ___

PSYCHIATRIC STATUS (cont)

CONFIDENCE RATINGS
Is the above information significantly distorted by:
P22. Client’s misrepresentation?

0 – No 1 – Yes
___

P23. Client’s inability to understand?
0 – No 1 – Yes

___

SEVERITY PROFILE

Problems 0 1 2 3 4 5 6 7 8

MEDICAL

EMPL/SUP

ALCOHOL

DRUG

LEGAL

FAM/SOC

PSYCH

9

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/NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken die zijn geoptimaliseerd voor prepress-afdrukken van hoge kwaliteit. De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 5.0 en hoger.)
/NOR <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>
/PTB <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>
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/SVE <FEFF0041006e007600e4006e00640020006400650020006800e4007200200069006e0073007400e4006c006c006e0069006e006700610072006e00610020006f006d002000640075002000760069006c006c00200073006b006100700061002000410064006f006200650020005000440046002d0064006f006b0075006d0065006e007400200073006f006d002000e400720020006c00e4006d0070006c0069006700610020006600f60072002000700072006500700072006500730073002d007500740073006b00720069006600740020006d006500640020006800f600670020006b00760061006c0069007400650074002e002000200053006b006100700061006400650020005000440046002d0064006f006b0075006d0065006e00740020006b0061006e002000f600700070006e00610073002000690020004100630072006f0062006100740020006f00630068002000410064006f00620065002000520065006100640065007200200035002e00300020006f00630068002000730065006e006100720065002e>
/ENU (Use these settings to create Adobe PDF documents best suited for high-quality prepress printing. Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.)
>>
/Namespace [
(Adobe)
(Common)
(1.0)
]
/OtherNamespaces [
<<
/AsReaderSpreads false
/CropImagesToFrames true
/ErrorControl /WarnAndContinue
/FlattenerIgnoreSpreadOverrides false
/IncludeGuidesGrids false
/IncludeNonPrinting false
/IncludeSlug false
/Namespace [
(Adobe)
(InDesign)
(4.0)
]
/OmitPlacedBitmaps false
/OmitPlacedEPS false
/OmitPlacedPDF false
/SimulateOverprint /Legacy
>>
<<
/AddBleedMarks false
/AddColorBars false
/AddCropMarks false
/AddPageInfo false
/AddRegMarks false
/ConvertColors /ConvertToCMYK
/DestinationProfileName ()
/DestinationProfileSelector /DocumentCMYK
/Downsample16BitImages true
/FlattenerPreset <<
/PresetSelector /MediumResolution
>>
/FormElements false
/GenerateStructure false
/IncludeBookmarks false
/IncludeHyperlinks false
/IncludeInteractive false
/IncludeLayers false
/IncludeProfiles false
/MultimediaHandling /UseObjectSettings
/Namespace [
(Adobe)
(CreativeSuite)
(2.0)
]
/PDFXOutputIntentProfileSelector /DocumentCMYK
/PreserveEditing true
/UntaggedCMYKHandling /LeaveUntagged
/UntaggedRGBHandling /UseDocumentProfile
/UseDocumentBleed false
>>
]
>> setdistillerparams
<<
/HWResolution [2400 2400]
/PageSize [612.000 792.000]
>> setpagedevice

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