ALCOHOL AND DRUG CLINICAL EVALUATION

Please correct the errors described below.

CONFIDENTIALITY: The information you give below will be held in strict confidence and will be used for establishing your file. Any misrepresented or false information places you at risk of being re-evaluated (at your cost) or discharged.

First, Middle, Last
Certificate of Completion

I. Marital Status

years or months
years or months
MM/YY

Date(s): 1st:

MM/YY
MM/YY

Date(s): 2nd:

MM/YY
MM/YY

Date(s): 3rd:

MM/YY
MM/YY

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II. Family Background

How many brothers and sisters do you have?

How many step-brothers and sisters do you have?

III. Education

(e.g., certified electrician, licensed contractor, certified accountant)

IV. Employment

History of Employment: (start from present)

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Month(s)/Year(s)

V. Military Experience

VI. Financial

MM/YY

VII. Physical and Emotional Checklist

How often have you experienced each of the following in the last two months?

VIII. Health

IX. Legal History

Referral Source:

want the Referral Source notified of the results of the evaluation.

i.e., active TPO, Special Conditions of Bond
Title, First, Middle, Last
e.g., Sentinel, JCS, PPS, SE Corrections, County

DUI History

MM/YY
Reason for being stopped and what happened afterwards.

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MM/YY
Reason for being stopped and what happened afterwards.

Arrest(s) History (other than DUI)

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Evaluator’s Notes (Go to the next section)

X. Alcohol And Drug History

Please answer the following questions on the basis of how you have drank alcohol or used drugs In the past 10 years. If you have not been drinking for a length of time, there will be a space to list that in. We need to know how you have drank alcohol or used drugs in the past

In the past, did:

days
e.g., one beer, six pack, pint

In your lifetime, have you ever used:

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Pamela Weeks, MBA, CACII, NCACI, SAP, ASAM DBHDD DUI Clinical Evaluator, Treatment Provider, # 2770, Certified Prime For Life Instructor #1086

3315 East Ponce de Leon Ave. Scottdale, GA. 30079

Phone: 678-671-2384 Cell: 404-323-7370 Fax: 678-712-5384

pamelaweeks@counselingsecure.com

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