ADSAP Questionnaire

Name

First Last

Date

Date of legal charge (located under DUI, Implied Consent, BAC or Alcohol Violation on driving record):

Do you have any health problems? (If yes, please describe)

Are you on any medications? (If yes, please list):

Do you use tobacco products?

Have you ever been tested for TB? (If yes, please give date and results)

Have you ever participated in high-risk HIV behaviors?

Describe current relationship with your family, (Parents, siblings, spouse, children, etc.)

Do you have any substance abuse history or mental health problems in your family background?(Required)

If yes, please explain.

Have you ever thought about or attempted suicide?

Do you have any urgent or critical needs to discuss with a counselor?

Alcohol use history:

How old were you the first time you drank alcohol?

How often do you use alcohol? (Give range)

Date of last use:

When you drink/drank, how much do/did you drink (quantity)? (Give minimum/max range)

Drug use history:

Drug 1:

Age of first use:

Date of last use:

How much have you used this drug in the past year?

How often have you used this drug in past year

Drug 2:

Age of first use:

Date of last use:

How much have you used this drug in the past year?

How often have you used this drug in past year

Have you ever received alcohol / drug treatment?

Inpatient (Where and When)

Outpatient (Where and When)

Describe the event of your legal charge in terms of how much alcohol/drug consumed and over what period of time.

Please tell us where you were drinking/using substances prior to the event above:

Comments or other important information not listed above:

Ex: out of state issues, court paperwork?

1. What was the date of your arrest?

2. Which city were you arrested in?

3. Please list the last location where you had your last drink prior to being arrested. (ex: home/hotel/ bar/nightclub, etc.)

4. If your last drink was from a bar/nightclub/restaurant, etc., please indicate the name:

5. Did you visit any other bars/nightclubs/restaurants, etc., the same day you were arrested? If yes, please list the names of the establishments you visited: