An Ideal Assessment
- Substance use history, noting whether the problem is occurring right now or took place in the recent or distant past and including the date of last use, as well as how much was regularly used. The history should determine whether the client is currently intoxicated, withdrawing, or abstinent.
- Age, gender, marital or partner status, and educational status
- Occupation and financial status
- Culture and ethnicity
- Medical history (some programs also include laboratory tests and a physical exam conducted by a medical professional)
- Psychiatric/psychological history and assessment for current problems
- Degree of a client’s insight into the substance problem
- Treatment history
- Collateral information from previous treatment experiences and other care. If the client grants permission, it’s also helpful to get information from his or her spouse or partner, relatives, or friends.
- Readiness and motivation for dealing with the problem
- Need for various kinds of support—medical, financial, legal, housing, marital, and other family support
- Religious affiliation
- Identification of the client’s strengths, supports, and resources. While problems are often the focus of assessment and treatment, it’s important to identify the assets a person might draw upon in recovery.
Excerpt From: Anne M. Fletcher. “Inside Rehab.” iBooks. https://itunes.apple.com/us/book/inside-rehab/id540067140?mt=11