Behavioral Health-ADULT CLIENT INTAKE AND ASSESSMENT QUESTIONNAIRE 10.11.22

Urban Inter-Tribal Center of Texas

1261 Record Crossing Rd, Dallas TX 75235
Client Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Age*
Social Security Number*
Please enter a social security number.
Tribe*
Marital Status*
Spouse Name*
Spouse Age*
Spouse Tribe/Race*
Presenting Problem: Describe the problem that brought you here today*
Please check all of the behaviors and symptoms that you consider problems.*

DistractibilityHyperactivityImplusivityBoredomPoor Memory/ConfusionSeasonal mood changesSadness/DepressionLoss of pleasureHopelessnessAggressive/FightsFrequent argumentsAnger/IrritabilityHomicidal thoughtsFlashbacksHearing VoicesVisual HallucinationsChange in appetiteLack of motivationWithdrawal from peopleAnxiety/WorryPanic attacksFear away from homeSocial discomfortObsessive thoughtsCompulsive BehaviorProblems with pornographyParenting problemsSexual ProblemsRelationship ProblemsWork/School ProblemsAlcohol/Drug useRecurring, disturbing memoriesSuspicion/ParanoiaRacing ThoughtsExcessive EnergyWide mood swingsSleep ProblemsNightmaresEating ProblemsGambling ProblemsThoughts of deathSelf-harm behaviorsCrying SpellsLonelinessLow Self WorthGuilt/ShameFatigue/TiredOther
Are your problems affecting any of the following?*

Handling everyday tasksSelf-esteemRelationshipsHygieneWork/SchoolHousingLegal MattersFinancesRecreational activitesSexual ActivityHealthPhysical
What Native/Traditional activities do you participate in?*
If non, would you like to?*

YesNo
You were raised by:*

Natural ParentsMotherFatherGrandparentsAdoptive Family
Atmosphere of childhood home:*

LovingSupportiveVerbally AbusivePhysically AdusiveNeglectedOther
What kind of discipline was used?*

SpankingGroundingTime OutYellingNo DisciplineOther
By whom were you disciplined?*
Please check if you have experienced any of the following types of trauma or loss*

Emotional AbuseNeglectLived in a foster homeSexual AbuseViolence in the homeMultiple family movesPhysical AbuseCrime VictimHomelessnessVerbal AbuseParent IllnessLoss of a loved oneParent(s) substance abusePlaced a child for adoptionBoarding schoolTeen PregnancyParent DivorceMilitary Deployment
Were you responsible for your brothers and sisters, as if you were their parent?*

YesNo
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:*

Natural ParentsMotherFatherGrandparentsOther
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?*

LovingSupportiveVerbally AbusivePhysically AbusiveNeglectedOther
If you are single, do you have a boyfriend/girlfriend:*

YesNo
Are you in a steady relationship?*

YesNo
Does your boyfriend/girlfriend use alcohol or other drugs?*

YesNo
If yes, how often?

Education*

	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?*

YesNo
If yes, for what reason?
Have you ever failed a grade?*

YesNo
If yes, for what reason?
Employment Status*

Working F/TWorking P/TUnemployedStudentRetired
Type of Work*
Is your work providing the wages sufficient for you and your family?*

YesNo
Stress level of this position?*

LowMediumHigh
Military Service?*

YesNo
If yes, what branch?
Did you serve in the combat zone?*

YesNo
If yes, where?
Legal History*

Now on Parole/ProbationArrest(s) not substance relatedArrest(s) substance relatedCourt ordered treatmentChild Protective ServicesJail/PrisonNo Legal Problems
Name and Phone # of PO
How many times?
Total time served?
Do you have any current medical problems?*

YesNo
If so, describe.
List your medications.*

Domestic Violence:*

	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:*

	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:*

	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?*

YesNo
If so, whom and type of illness?
Have you been treated for mental health issues?*

YesNo
If so, when and where?

Substance History*

	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)*

	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?*

YesNo
If so, how old were you?

Substance Use Questions*

	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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Urban Inter-Tribal Center of Texas