Urban Inter-Tribal Center of Texas
1261 Record Crossing Rd, Dallas TX 75235
Client Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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-
Month
-
Day
Year
Date
Age
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Social Security Number
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Please enter a social security number.
Tribe
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Marital Status
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Spouse Name
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Spouse Age
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Spouse Tribe/Race
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Presenting Problem: Describe the problem that brought you here today
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Please check all of the behaviors and symptoms that you consider problems.
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Distractibility
Hyperactivity
Implusivity
Boredom
Poor Memory/Confusion
Seasonal mood changes
Sadness/Depression
Loss of pleasure
Hopelessness
Aggressive/Fights
Frequent arguments
Anger/Irritability
Homicidal thoughts
Flashbacks
Hearing Voices
Visual Hallucinations
Change in appetite
Lack of motivation
Withdrawal from people
Anxiety/Worry
Panic attacks
Fear away from home
Social discomfort
Obsessive thoughts
Compulsive Behavior
Problems with pornography
Parenting problems
Sexual Problems
Relationship Problems
Work/School Problems
Alcohol/Drug use
Recurring, disturbing memories
Suspicion/Paranoia
Racing Thoughts
Excessive Energy
Wide mood swings
Sleep Problems
Nightmares
Eating Problems
Gambling Problems
Thoughts of death
Self-harm behaviors
Crying Spells
Loneliness
Low Self Worth
Guilt/Shame
Fatigue/Tired
Other
Are your problems affecting any of the following?
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Handling everyday tasks
Self-esteem
Relationships
Hygiene
Work/School
Housing
Legal Matters
Finances
Recreational activites
Sexual Activity
Health
Physical
What Native/Traditional activities do you participate in?
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If non, would you like to?
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Yes
No
You were raised by:
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Natural Parents
Mother
Father
Grandparents
Adoptive Family
Atmosphere of childhood home:
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Loving
Supportive
Verbally Abusive
Physically Adusive
Neglected
Other
What kind of discipline was used?
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Spanking
Grounding
Time Out
Yelling
No Discipline
Other
By whom were you disciplined?
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Please check if you have experienced any of the following types of trauma or loss
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Emotional Abuse
Neglect
Lived in a foster home
Sexual Abuse
Violence in the home
Multiple family moves
Physical Abuse
Crime Victim
Homelessness
Verbal Abuse
Parent Illness
Loss of a loved one
Parent(s) substance abuse
Placed a child for adoption
Boarding school
Teen Pregnancy
Parent Divorce
Military Deployment
Were you responsible for your brothers and sisters, as if you were their parent?
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Yes
No
If yes, at what age?
How many times have you been married?
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How many times have you been divorced?
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How many children do you have?
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What are their ages?
Do you live with:
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Natural Parents
Mother
Father
Grandparents
Other
As a young person (teen), who did you trust to share a problem with?
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As an adult, who did you trust to share a problem with?
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Atmosphere of current home?
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Loving
Supportive
Verbally Abusive
Physically Abusive
Neglected
Other
If you are single, do you have a boyfriend/girlfriend:
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Yes
No
Are you in a steady relationship?
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Yes
No
Does your boyfriend/girlfriend use alcohol or other drugs?
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Yes
No
If yes, how often?
Education
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Yes
Year
Major Area of Study
High School Graduate
GED
Dropped out of School
Trade School
Associate's Degree
Undergraduate Degree
Graduate Degree
Have you ever been suspended or expelled from school?
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Yes
No
If yes, for what reason?
Have you ever failed a grade?
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Yes
No
If yes, for what reason?
Employment Status
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Working F/T
Working P/T
Unemployed
Student
Retired
Type of Work
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Is your work providing the wages sufficient for you and your family?
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Yes
No
Stress level of this position?
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Low
Medium
High
Military Service?
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Yes
No
If yes, what branch?
Did you serve in the combat zone?
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Yes
No
If yes, where?
Legal History
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Now on Parole/Probation
Arrest(s) not substance related
Arrest(s) substance related
Court ordered treatment
Child Protective Services
Jail/Prison
No Legal Problems
Name and Phone # of PO
How many times?
Total time served?
Do you have any current medical problems?
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Yes
No
If so, describe.
List your medications.
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Domestic Violence:
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Yes
No
Do you feel controlled or isolated by your partner?
Do you ever feel afraid of your partner?
Has your partner ever threatened to hurt you or someone close to you?
Have you ever been hit, kicked, slapped, pushed or shoved by your partner?
Have you ever been forced or pressured to have sex when you did not want to?
Please check what you believe about you:
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Yes
No
Have you had difficulty reasoning and solving problems?
Have you forgotten things that have happened recently?
Have you had trouble keeping your attention on any activity for long?
Have you had any difficulty doing activities involving concentration and thinking?
During the past month, I have been bothered by feeling down, depressed, or hopeless.
During the past month, I have often been bothered by little interest or pleasure in doing things.
Do you often worry or feel nervous?
Are you often fearful of interacting with other people?
Do you feel jittery, short of breath, or like your heart is racing?
Do you ever feel like you might lose control or fear that you may be “losing it”?
Do you have problems falling asleep or staying asleep?
Do you have problems with either eating too much or too little?
In your life, have you ever had any experience that was so upsetting, frightening or horrible that you:
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Yes
No
Have nightmares about it, think about it, when you do not want to?
Try hard not to think about it or go out of your way to avoid situations that remind you of it?
Are you constantly on guard, watchful, or easily startled?
Feel numb or detached from others, activities, or your surroundings?
Do you or anyone in your family have a significant mental health illness?
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Yes
No
If so, whom and type of illness?
Have you been treated for mental health issues?
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Yes
No
If so, when and where?
Substance History
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Yes
No
Age of 1st use?
How Long?
When did you last use??
Alcohol
Cocaine or Crack Cocaine
Ecstasy (Molly, MDMA)
GHB
Heroin
Inhalant(s)
K2 (Spice, synthetic, cannabis)
LSD or Hallucinogens
Marijuana
Meth
Tobacco (cigarettes, vape)
Prescription Medication History (if not used as prescribed)
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Yes
No
Age of 1st use?
How long?
When did you last use?
Ativan (Lorazepam)
Adderall
Ambien (Zolpidem)
Clonazepam (Klonopin)
Codeine liquid (cough syrups)
Codein pills (tylenol 3, ect.)
Darvocet
Demerol
Dilaudid (Hydromorphone)
Fentanyl (Actiq, Duragesic, Fentora)
Lunesta
Librium
Methadone
Morphine (MS Contin)
Oxycontin (Oxycodone. Percocet)
Oxymorphone (Opana)
Ritalin
Suboxone (Buprenorphine)
Tramadol
Vicodin (Hydrocodone)
Vyvanse
Any other prescription Medication that is not listed?
Did you ever use alcohol or drugs with your parents?
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Yes
No
If so, how old were you?
Substance Use Questions
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Yes
No
Did your drinking/using drugs cause family problems?
Did your parents drinking/using drugs cause family problems?
Has a family member or a close friend ever expressed concern about your substance use?
Do you get angry and sometimes lose control when you are drinking/drugging?
Have you decreased or given up certain activities because of your alcohol/drug use?
Has alcohol/drugs use caused legal problems?
Did alcohol/drug use cause you to miss important family, school, work obligations?
Did alcohol/drug use cause financial problems?
Did/Do you continue drinking/using drugs even though you have personal/financial problems?
Are you interested in substance abuse inpatient treatment?
Have you ever received treatment for substance abuse? If yes, where?
Are you interested in free Narcan training for emergency drug overdoses?
Are you interested in free Dispose RX to safely dispose of unused medications?
Client Signature
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