(717) 601-2555
Info@r3recoveryservices.com
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Are you currently employed?YesNo
Have you been previously diagnosed?YesNo
Is your job at risk?YesNo
Do you need assistance with FMLA Paperwork?YesNo
What led to you seeking treatment at this time?
Willingness for treatment?YesNo
Substance of Choice:
Used last 30 days:YesNo
Method of Use:
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Do you find that it takes more or less alcohol or drugs to get the same effect as it once did?MoreLessNeither
Have you ever had a blackout?YesNo
Have you ever tried to hide your substance use from others? YesNo
Have you ever tried to cut down or stop your substance use? YesNo
Do you feel you have a problem with substances?YesNo
Have you ever driven while under them influence of substances?YesNo
As a result of using substances have you ever neglected:FamilySchoolWorkOther
Have you ever lost friends or relationships because of substance use?YesNo
Has anyone ever said they were concerned about your substance use?YesNo
Have you decreased your social/recreation activities because of substances?YesNo
Have you ever felt bad or guilty about your substance use? YesNo
What negative consequences have you experienced due to drug or alcohol abuse?
Highest Grade/Degree Completed:
Can you read and write? YesNo
Have you had vocational training?
Are you a student? YesNo
How do you learn best? By seeing thingsBy hearing thingsBy touching thingsBy writing thingsBy reading thingsOther
Other:
Do you have any diagnosed learning disabilities including attention deficit hyperactivity disorders? YesNo
Explain:
Does this affect you today?YesNo
How?
Do you need assistance developing job skills or find a job?YesNo
Have you ever missed work or lost a job due to your substance use?YesNo
What is your current financial status?Self SufficientSupported by FamilyStruggling
How does your financial status affect your addiction?
Do you have other resources and/or benefits? (SNAP, pension, rental assistance?)YesNo
