Urban Inter-Tribal Center of Texas
1261 Record Crossing Rd, Dallas TX 75235
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Street Address Line 2
State / Province
Postal / Zip Code
Date of Birth
Social Security Number
Please enter a social security number.
Presenting Problem: Describe the problem that brought you here today
Please check all of the behaviors and symptoms that you consider problems.
Seasonal mood changes
Loss of pleasure
Change in appetite
Lack of motivation
Withdrawal from people
Fear away from home
Problems with pornography
Recurring, disturbing memories
Wide mood swings
Thoughts of death
Low Self Worth
Are your problems affecting any of the following?
Handling everyday tasks
What Native/Traditional activities do you participate in?
If non, would you like to?
You were raised by:
Atmosphere of childhood home:
What kind of discipline was used?
By whom were you disciplined?
Please check if you have experienced any of the following types of trauma or loss
Lived in a foster home
Violence in the home
Multiple family moves
Loss of a loved one
Parent(s) substance abuse
Placed a child for adoption
Were you responsible for your brothers and sisters, as if you were their parent?
If yes, at what age?
How many times have you been married?
How many times have you been divorced?
How many children do you have?
What are their ages?
Do you live with:
As a young person (teen), who did you trust to share a problem with?
As an adult, who did you trust to share a problem with?
Atmosphere of current home?
If you are single, do you have a boyfriend/girlfriend:
Are you in a steady relationship?
Does your boyfriend/girlfriend use alcohol or other drugs?
If yes, how often?
Major Area of Study
High School Graduate
Dropped out of School
Have you ever been suspended or expelled from school?
If yes, for what reason?
Have you ever failed a grade?
If yes, for what reason?
Type of Work
Is your work providing the wages sufficient for you and your family?
Stress level of this position?
If yes, what branch?
Did you serve in the combat zone?
If yes, where?
Now on Parole/Probation
Arrest(s) not substance related
Arrest(s) substance related
Court ordered treatment
Child Protective Services
No Legal Problems
Name and Phone # of PO
How many times?
Total time served?
Do you have any current medical problems?
If so, describe.
List your medications.
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:
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:
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?
If so, whom and type of illness?
Have you been treated for mental health issues?
If so, when and where?
Age of 1st use?
When did you last use??
Cocaine or Crack Cocaine
Ecstasy (Molly, MDMA)
K2 (Spice, synthetic, cannabis)
LSD or Hallucinogens
Tobacco (cigarettes, vape)
Prescription Medication History (if not used as prescribed)
Age of 1st use?
When did you last use?
Codeine liquid (cough syrups)
Codein pills (tylenol 3, ect.)
Fentanyl (Actiq, Duragesic, Fentora)
Morphine (MS Contin)
Oxycontin (Oxycodone. Percocet)
Any other prescription Medication that is not listed?
Did you ever use alcohol or drugs with your parents?
If so, how old were you?
Substance Use Questions
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?
Should be Empty: