ANTA Alcohol & Other

Drugs Toolbox
Sample Assessment
Form

Sample Assessment Form

(front page)

Case Summary:

Client’s Name:

Current Address:

Contact Telephone:

Age and Date of Birth: Gender:

Ethnic/cultural background:

Is an interpreter required?: If yes… what language………………………………………………

Does the client have children? (if yes provide details – ages, with whom do they live)

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Has client been referred by others or self?

Referral information and source:

Referral problem stated:

Description of general presenting problems and relevant AOD issues:

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Date interviewed:

Name and position of interviewer:

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Details of substance use
Specify Drug(s):

Age of first use:

Age of first regular use:

Route of administration:

Average daily use:

Number of days used in past seven days:

Number of days used in past four weeks:

Last use:

Period of time client has used daily:

Comments regarding substance use

For example, abuse, dependence, intoxication, withdrawal.

Details of prescribed medications

Specify medications:

Prescribed dose:

Taking medication as prescribed (if no state reason):

Duration of treatment:

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Reason for prescription:

Prescribing doctor/health practitioner:

Comments regarding prescribed medication

For example past history of prescribed medication.

Other drug use in the family

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Genogram
Sample genogram

An example of a family genogram is provided below.

o Female symbol

 Male symbol

∆ Unknown sex

___ Married

Client lives with those closed in circle

----- De facto relationship

/ Separation (add year if desired)

// Divorce (add year if desired)

 Death (of a male) add year if known

1990 1983

1990

1994 Client

Insert clients genogram:

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Medical/physical assessment
Current problems in need of immediate attention:

(Tick as appropriate)
Allergies Gastrontestinal Cardiac problems
 problems
 
Hepatitis C Seizures/fits/ Pregnancy
 epilepsy
 
Hepatitis B Respiratory (eg Chronic pain
 asthma)
 
HIV Diabetes Head injuries
  
Liver Disease Skeletal injuries
  
Dental Other (please specify)

Past relevant medical history

General hospital admissions (including number of GP/casualty attendances, ambulance trips.

Specify date, hospital, reasons for admission, length of stay)

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Medical history

Medication

Physical appearance

Physical state

Other comments (including impact of substance use on general health, weight loss, eating
pattern, nutrition)

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Social

Accommodation

Employment/Education

Finance

Social networks/Relationships

Legal history

Current legal problems

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Psychological/emotional

General appearance

Behaviour

Mood

Thought

Level of awareness

Previous psychiatric history (Include family history of mental

illness)

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 Currently receiving treatment

Yes

No

Name :

Contact No:_

Suicide/self-harm risk assessment (tick applicable

items)

Sense of hopelessness/worthlessness

Ideation (do you ever think about killing/harming yourself?)*

Intent (do you want to kill/harm yourself?)

Plan (how would you do it?)

Lethality (is the method likely to be lethal?)

Accessibility?

Previous attempts?

Suicide/attempted suicide of significant other?

* If evidence of suicidal ideation, include it on the summary sheet

Comments

Is a full psychiatric assessment required? Yes/No

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If yes, the form ‘Current Mental State’ is to be completed by a psychiatrist,
psychologist or other appropriately qualified clinician. (see appendix 1)

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Other comments

Readiness to change

Client’s goals

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Individual Treatment Plan

Immediate plan

Medium

Long-term

Main goals to be addressed by client and care plan manager:

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 Is client familiar with the agency conditions and contract?

Yes

No

If not, explain

Does the client know about their rights regarding confidentiality,

grievance procedures, etc.

Yes

No

If not, explain policy:

Any special needs or services required?

Yes

No

If so, specify:

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Specify services to be provided by your agency and other relevant
organisations:

Future contact date and time required:

Is action to be taken by either party before next appointment?

Specify by whom the action is to be taken?

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Appendix 1
Current Mental State Examination

NOTE – Current Mental State is to be completed by a psychiatrist, psychologist or other

qualified individual with psychiatric training.

Appearance
(eg physical presentation, conscious state)

Behaviour
(eg psychomotor activity, mannerisms, social appropriateness)

Conversation
(eg Form/coherence, flow, content/themes)

Thought Disorder
(eg delusions)

Perceptual disorder
(eg hallucinations/illusions)

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Mood

Intellectual functioning
(memory, attention, orientation, insight)

NOTE – If client demonstrates objective/subjective intellectual difficulties, and is at least five

days post-detox and is not currently drug-affected, you may consider administering the
cognitive status examination (CSE0 to determine if further cognitive assessment may be
warranted).

Comments

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