Chrysalis Intake Packet

Chrysalis Intake Packet

350 E 11th Ave. Eugene, OR 9740 (541) 683-1641
If you require assistance in completing this form, please call the front office to schedule a time with a Peer Support Specialist who will help
Date form completed:*

MonthDayYear
Date
Seeking services for:*
Why are you seeking services now? What goals are you wishing to address while in services?*

0/140
What do you believe are your strengths? What interests and/or hobbies do you have?
Name:*
Previous names used:
Address

Address

Street Address Line 2

CityState

Zip
Phone:
Is it ok to identify ourselves when we call?

YesNo
E-mail
example@example.com
Is it ok to contact you through e-mail?

YesNo
Date of Birth:*

MonthDayYear
Date
Have you ever been a past Chrysalis client?*

YesNo
If yes, what was your client number?
Do you have any friends or family currently attending Chrysalis?
Is yes, what are their names?
Referred by:
If not referred: Where did you hear about us?
Race/Ethnicity:*
Marital Status:*
Living Situation:*
Highest Grade of School Completed:*
Gender Identity:*
Preferred Pronouns
Sexual Orientation:*
Household Gross monthly income:*
Source of Income:*
Source of Income:
Including yourself, list number & ages of people dependent on listed income:
Do you have OHP?*

YesNo
ID #:
Which CCO?

TrilliumPacific Source
Do you need assistance applying for OHP?

YesNo
Private Health Insurance, if any:
ID #:
Do you have an OMMP Card?

YesNo
If yes, do you plan on using it?

YesNo
Are you in a Methadone/Suboxone Program?

YesNo
If you have an OPEN case, your DHS Child Welfare Caseworker's name:
If under Parole and Probation, your Probation Officer's name:
Are DHS and/or Parole & Probation asking you to enter treatment?*

YesNo
Total number of arrests in your life:
Total number of DUII arrests in your life:
Veteran Status
If discharged, what type of discharge?
Demographics
Race*

Asian IndianChineseFilipinoKoreanVietnameseOther AsianNative HawaiianOther Pacific IslanderGuamanian or ChamorroSamoanBlack/African AmericanAmerican Indian/Alaskan NativeWhiteMore than One Race (Check all that apply)Unreported/Chose not to disclose
Ethnicity*

Mexican American, Chicano/aPuerto RicanCubanAnother Hispanic, Latino/a or Spanish OriginNot Hispanic, Latino/a, or Spanish OriginUnreported/ Chose not to disclose to report ethnicity
Sexual Orientation*

Lesbian or Gay - Clients who are emotionally and sexually attracted to people of their own gender.Heterosexual (or straight) – Clients who are emotionally and sexually attracted to people of a different gender.Bisexual – Clients who are emotionally and sexually attracted to people of their own gender and people of other genders.Other – Clients who identify themselves as queer, asexual, pansexual, or another sexual orientation not captured above.Don’t Know – Clients who self-report that they DO NOT know their sexual orientation.Chose Not to Disclose – Clients who chose not to disclose their sexual orientation.
Gender Identity*

Male – Clients who identify themselves as a man/male.Female – Clients who identify themselves as a woman/female.Transgender Man/Transgender Male/Transmasculine – Transgender clients who describe their gender identity as man/male.Transgender Woman/Transgender Female/Transfeminine – Transgender clients who describe their gender identity as woman/female.Other – Clients who DO NOT think that one of the four categories above describes them. Include clients who identify themselves as genderqueer and non-binary.Chose Not to Disclose – Clients who chose not to disclose their gender.
Dimension 1
Check any of the following that you experienced in the last year after you stopped using alcohol or other drugs:*

N/A (does not apply)Saw things that were not really thereSeizuresItching painsAgitationBurning sensations on or under skinTremors/shakesNumbnessHeard things that were not really thereFelt bugs crawling on or under skinNauseaFidgetyVomitingRestlessTrouble sleeping or sleeping a lotDizzinessHeavy sweatingDiarrheaAnxietyNervousnessDepressionHeadachesThoughts of suicide
ALCOHOL AND OTHER DRUG USE HISTORY
***For each of the following substances, please fill out completely. Include your present and past use over your entire lifetime.***
Frequency of use: Alcohol (liquor, beer, wine)
Method of use:
Age of 1st Use:
How long since last use:
Amphetamines (meth, MDMA, adderalll)
Method of use:
Age of 1st Use:
How long since last use:
Marijuana
Method of use:
Age of 1st Use:
How long since last use:
Nicotine (cigarettes, chew)
Method of use:
Age of 1st Use:
How long since last use:
Cocaine
Method of use:
Age of 1st Use:
How long since last use:
Heroin
Method of use:
Age of 1st Use:
How long since last use:
Opiates (opium, morphine)
Method of use:
Age of 1st Use:
How long since last use:
Synthetic Opiates/Opioid's
(Percocet, codeine, vicodin etc)
Method of use:
Age of 1st Use:
How long since last use:
Methadone
Method of use:
Age of 1st Use:
How long since last use:
Hallucinogens (mushrooms, LSD, mescaline, DMT, peyote)
Method of use:
Age of 1st Use:
How long since last use:
Sedatives
Method of use:
Age of 1st Use:
How long since last use:
Tranquilizers (benzos, valium)
Method of use:
Age of 1st Use:
How long since last use:
Barbiturates (Phenobarbital etc)
Method of use:
Age of 1st Use:
How long since last use:
Inhalants (glue, nitrous, paint)
Method of use:
Age of 1st Use:
How long since last use:
PCP (angel dust)
Method of use:
Age of 1st Use:
How long since last use:
Caffeine (Coffee, cola, tea)
Method of use:
Age of 1st Use:
How long since last use:
Other (kratom, poppers etc)
Method of use:
Age of 1st Use:
How long since last use:
Please list current prescriptions and/or provide a copy to the front office:

	Yes	No	N/A
Do you often take in larger amounts of substances and/or over a longer period than planned?
Have you ever tried to limit your use to certain times or amounts and failed to do so?
Do you spend a lot of time getting the substance, using it, and/or recovering from it?
Have you ever switched doctors to get more prescriptions?
Have you given up hobbies, or other activities because of your use of alcohol or other drugs?
Have you lost contact with friends or family because of your use of alcohol or other drugs?
Have you changed the kind of friends you have because of your drug use?
Have you missed work or school because of your alcohol or other drug use?
Has anyone ever complained about your drinking or using?
Has the quality of your work (including schoolwork) gone down due to your use of alcohol or other
Have you become less involved in your children's activities because of your use?
Has a doctor ever told you to quit using alcohol, nicotine or other drugs because your use was
Have you ever gone to work, or school while you were hung over or intoxicated?
Have you ever lost a job or had job problems due to your use of alcohol or other drugs?
Have you ever stolen drugs/alcohol or money to buy alcohol or other drugs?
Have you ever had legal problems due to your use of alcohol/drugs DUII, assault, etc?

DIMENSION 2: MEDICAL HISTORY
Are you under a doctor's care at this time?*

YesNo
If so, please give name and address:
When was the last time you saw a physician?
List any surgery you have had:
List all current medical problems (within the past year) requiring medical treatment:
Have you had any blood tests done since you last used?

YesNo
If so, please explain:
Are you pregnant?

YesNo
If yes, are you receiving prenatal care??

YesNo
If yes, who is your health care provider?
If no, do you want referrals?

YesNo
INFECTIOUS DISEASE RISK ASSESSMENT FORM

	Yes	No	Don't Know
Have you seen a doctor or other health care provider in the past 3 months?
Do you live or have you lived on the street or in a shelter?
Have you ever been in jail/prison/juvenile detention?
Have you ever been in a long-term care facility (nursing home, mental health hospital, or other hospital)?
Canada, Australia, New Zealand, Japan, Western Europe or Great Britain?
Are you a combat veteran?
In the past 12 months have you had a tattoo, ear/body piercing, acupuncture, or come into contact with someone else's blood?

Have you ever had any of the following? Check the appropriate boxes.

	No	Yes
Hepatitis
Heart problems
Skin infections
Diabetes
Kidney problems
Tuberculosis (TB)
Epilepsy/Seizures
Pancreatitis
Cancer
Asthma
Internal bleeding
Been in hospital (Other than childbirth)
Surgeries done or recommended
Other health problems

Dates and comments of any marked "yes
Where were you born?
Within the last 30 days, have you had any of the following symptoms lasting for more than 2 weeks:

NauseaFeverDrenching night sweats that were so bad you had to change your clothes or the sheets on the bedProductive coughShortness of breathLumps or swollen glands in the neck or armpitsLosing weight without meaning toDiarrhea (runs) lasting more than a weekBrown tinged urineFemale Bodied: Have you missed your last two periods?Extreme fatigueJaundice (yellow skin) or yellow eyes
Have you been told you have TB? Has anybody you know or have lived with been diagnosed with TB in the past year?
Have you ever had a positive skin test for TB? A test where they gave you a shot in your forearm, and a few days later a hard lump appeared
Have you ever been treated for TB?

YesNoDon't Know
Have you ever been told you have:

Hepatitis AHepatitis BHepatitis C
How would you judge your risk for being exposed to HIV (the AIDS virus)?
Low Medium or High
How would you judge your risk for being exposed to Hepatitis C?
Low Medium or High
Have you ever shared needles or syringes (“rigs”) to inject drugs?
Have you ever had a job that put you in danger of needle stick injuries or other types of blood contact?
In the past 12 months, have you, or anyone you have had sex with, had: syphilis, gonorrhea, herpes, chlamydia, nongonococcal urethritis, other sexually transmitted diseases or hepatitis?

The following 2 questions are asked to help with treatment planning. It is not required that you answer them to participate in assessment and/or treatment.

	Yes	No
1. Have you ever had a blood test for the HIV antibody?
If “no”, would you like a blood test?
If “yes”, have you been tested within the last six months?
2. Have you ever had a blood test for Hepatitis C virus?
If “no”, would you like a blood test?
If “yes”, have you been tested within the last six months?

To help find out if you are at increased risk for HIV, the virus known to cause AIDS, or Hepatitis C (HCV), please take a minute to answer the following questions.

	Yes	No	Don't Know
Did you receive a blood transfusion before 1992?
Have you received blood products produced before 1987 for clotting problems?
Was your birth mother infected with Hepatitis C virus during the time of your birth?
Have you been, or are you currently, on long-term kidney dialysis?
Have you had unprotected sex with someone who has the blood disease hemophilia?
Have you had unprotected sex with a person who injects drugs?
Have you had unprotected sex with a man who has sex with other men?
Have you had sex in exchange for money or drugs, or in order to survive?
Have you had sex with more than one person in the past 6 months? Any type of vaginal, rectal or oral contact without protection (condom or other barrier) with or without your
Have you had sex or shared needles to inject drugs with a person who has AIDS or who tested positive on the antibody test for AIDS/HIV disease or Hepatitis?
Have you ever injected drugs, even once?
Have you ever been pricked by a needle or syringe that may have been infected with HIV
Have you ever had a drinking problem that required medical care or counseling?
Have you ever been told or thought that you have a drinking problem?

If you answered “no” to all the questions, you are not at increased risk for HIV/AIDS or Hepatitis C.

If you answered “yes” or “don't know” to any question, you may be at risk for HIV/AIDS or Hepatitis C. If you would like information on how to get tested for TB, HIV or hepatitis, please ask any staff member for details.
DIMENSION 3

Have you experienced any of the following within the last 12 months:

	Yes	No
Have you been hospitalized for mental or emotional problems?
Have you had any outpatient visits for mental or emotional problems?
Has anyone been trying to harm you or plot against you?
Have you seen things in magazines, in movies or on TV that have special messages for you?
Have you heard your thoughts out loud, as if you had a voice outside your head?
Have you felt that your thoughts were being broadcast out loud so others could hear them?
Have you felt that someone or something was putting thoughts into your head?
Have you felt that your thoughts were being taken away by someone or something?
Have you heard voices or sounds that no one else could hear?
Have you had any strange feelings in your body that others do not seem to have?
Have you seen things that other people didn't seem to see?
Do you have any ideas that are uninvited and occur over and over again?
Are there things you do over and over?
Are there things you must do in a certain way, and if they are not done that way, you must repeat
Have you ever borrowed money to gamble?
Have you ever missed being somewhere because you were gambling?
Do you have a history of head trauma?
Binge eating
Fasting, not eating
Violent behavior
Thoughts of suicide, harm to self
Attempted suicide
Thoughts about harming someone else

If you answered yes to any of these questions, please explain
DIMENSION 3
Adverse Childhood Experience (ACE) Questionnaire

	Yes	No
Did a parent or other adult in the household often... Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
Did a parent or other adult in the household often... Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
Did an adult or person at least 5 years older than you ever... Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you?
Did you often feel that... No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
Did you often feel that... You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed
Were your parents ever separated or divorced?
Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Was a household member depressed or mentally ill or did a household member attempt suicide?
Did a household member go to prison?

Now add up your “Yes” answers. This is your ACE Score
Are you concerned about your safety?

YesNoUnsure
If yes, are you currently in a safe place?

YesNoUnsure
If no, do you have a safety plan?

YesNoUnsure
DIMENSION 4

	Very	A lot	Somewhat	A Little	Not at All
In the last year, how important have drugs/alcohol been in your life?
How troubled or bothered have you been in the past year by alcohol problems?
How troubled or bothered have you been in the past year by other drug problems?
How important to you now is treatment for alcohol problems?
How important to you now is treatment for other drug problems?
If substance abuse treatment is recommended for you, how open will you be to treatment?

Are you seeking services here voluntarily?

YesYes, but there is also legal, family or other pressure to seek services.No, I am not seeking services willingly, I have legal, family, or other pressure to seek services.
LEGAL HISTORY:

Incident : Date : Court : Alcohol/Drug related? BAC: Disposition:
ARRESTS AND LEGAL ACTIVITIES:
Current involvement with Criminal Justice System (check all that apply):

Awaiting trialIncarcerated, post convictionIn other supervised programOn trialOn probation/paroleConvicted, awaiting sentencingWork releaseIncarcerated, pre trialDUII DiversionDrug CourtNoneOther
DIMENSION 5
Have you ever been in counseling/treatment (detox, out-patient, re-hab) before?

YesNo
What programs/agencies?
How long ago?
Were you mandated?
Did you complete?
Length of clean time after treatment?
Were you involved in aftercare/continuation care?
If you were in counseling/treatment before but did not complete, why didn't you?
DIMENSION 5

	Always	A lot	Sometimes	Rarely	Never
How often do you try to stop using or drinking, but then use or drink anyway?
How often do you find yourself thinking about the next time you can use or drink?
How often do you crave alcohol and/or other drugs?
How often do you have alcohol or drug using dreams?
How often do you get impatient waiting to use alcohol/other drugs?

What if any, of the following reasons cause you to use/drink:

Does not applyRelationship problemsBad memoriesBoredomLonelinessWeight problemsDepressionAngerCertain placesCertain peopleStressOther
Describe:
Dimension 6
Housing:
How would you rate your housing?

StableUnstable risk eviction or having to moveHomeless
Religion/Spirituality
Do you belong to a spiritual or religious group?

YesNo
If yes, please list:
EDUCATION-VOCATION
How well do you read and write?

Needs improvingOKWell
Have you had any technical/trade training?

YesNo
If yes, which field?
Do you have plans to further your education or to get more training?

YesNo
If yes, what are your plans?
Family

In the past year, have you had problems with the following due to your use of alcohol or other drugs?

	Yes	No	No Contact	NA
Your spouse/partner
Your children
Your mother
Your father
Your siblings
Others

Do you live with anyone who uses alcohol or other drugs?
If you have family or significant others who live with you, will they support you if treatment is advised?
If you have family or significant others who live with you, will they support you if treatment is advised?
In the last year, have you been afraid of being victimized or abused by someone in your household?

YesNo
If yes, please explain:
Social-Recreation
What DRUG FREE support(s) do you have?

Immediate familyExtended familyClubSupport GroupCounselorSchoolHobbiesFriendsChurchCoworkersSportsDoctorPetsExerciseNone
How often do you use self-help groups?
With whom do you drink/use?
Where do you do most of your drinking/using?
How many of your friends use substances?
Financial
Rate your finances:
Cultural Identification
In terms of culture, how do you define yourself? Examples: Native American, African American, Mexican American, Asian, European, etc
Did you identify with that background? If so, how? If not, why not?
Thank You

Congratulations. You have completed the intake data packet. A Chrysalis staff member will contact you shortly.
Should be Empty:

Chrysalis Intake Packet

Demographics

Dimension 1

ALCOHOL AND OTHER DRUG USE HISTORY

Synthetic Opiates/Opioid's

DIMENSION 2: MEDICAL HISTORY

INFECTIOUS DISEASE RISK ASSESSMENT FORM

DIMENSION 3

DIMENSION 3

Adverse Childhood Experience (ACE) Questionnaire

DIMENSION 4

LEGAL HISTORY:

ARRESTS AND LEGAL ACTIVITIES:

DIMENSION 5

DIMENSION 5

Dimension 6

Housing:

Religion/Spirituality

EDUCATION-VOCATION

Family

Social-Recreation

Financial

Cultural Identification

Thank You