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Pre-Assessment Information
Your Contact Information
Your Name
First Name Last Initial
Are you inquiring for yourself or for another person?

Help for myself Help for another person
If the Client will be someone else, what is your connection to the Client?
Preferred Phone Number
Alternate Phone Number
Your e-mail
In what city do you require service?
Will travel be required during service?

Yes, travel will be required during service. No, travel will not be required during service. Not sure whether travel will be required.
Which service do you require?

24/7 Sober companion Daily or Nightly Sober Coach Sober Escort (travel to and from specific location for a specific time period) Not sure which type of service will be needed
Client Information
Gender

Male Female
Age
Is the Client currently in rehab?

Yes, Client is currently in rehab. No, Client is not in rehab.
Has the Client been to rehab at least once?

Client has been in rehab at least once. Client never has been to rehab.
Which drugs present problems for Client?

Alcohol Cocaine Heroin Amphetamine Prescription Drugs Marijuana
Where will Client live while we provide service?

Client will live alone. Client will live with his/her family. Client will live with roommate(s). Children will be present in the home. Client will be traveling (staying in hotels or with friends or family).
What days will you require service?

Monday Tuesday Wednesday Thursday Friday Saturday Sunday 7 Days Per Week
Does the Client currently suffer from any of the following?

Asthma High Blood Pressure Low Blood Pressure Epilepsy Arthritis Diabetes Dizziness/fainting Heart Disease High Cholesterol Other I am unaware of any serious physical condition at this time.
Has Client been diagnosed with any of these conditions?

Depression Anxiety Bipolar Disorder Borderline Personality Disorder ADD or ADHD Other disorder - not listed There is no co-occurring mental disorder.
Current Medication Status:

Client is currently taking medication as prescribed. Client is not taking medication as prescribed. I don't know whether Client is taking medication as prescribed.
Please list any prescription medications Client is currently taking.
How would you describe Client's nutritional habits?

Bad Good Optimal Unknown
Please include any additional information you feel will be helpful prior to our telephone assessment.
How do you want to be contacted?

Contact me via phone. Contact me via email.
Should be Empty:

Pre-Assessment Information

Your Contact Information

Client Information