COSIG CONFERENCE BROCHURE.pdf - Drexel University College ...

Co-occurring Substance Use and Mental Health Disorders
Chart Review Tool
Agency:
_________________________________________________________
Reviewer:
Date of Review: / /
PLEASE COMPLETE FOR THE PERSON UNDER REVIEW.
1. Date of First Contact with Agency: / /
2. Date of Birth: / /
3. Gender: |___|
1 – Male
2 – Female
4. Program or Unit: ____________________________________________
5. Was person screened for: |___|
1 – Substance use/abuse only
2 – Mental health only
3 – Both substance use and mental health
4 – Neither
6. Was person screened for physical health: |___|
1 – Yes
2 – No
7. Is there evidence of past or current substance abuse issues: |___|
1 – Yes
2 – No
8. Is there evidence of past or current mental health issues: |___|
1 – Yes
2 – No
9. Is there an assessment for: |___|
1 – Substance use/abuse only
2 – Mental health only
3 – Both substance use and mental health
4 – Neither
10. Is there evidence of integrated assessment: |___|
1 – Yes
2 – No
3 – No assessment
11. Is there evidence of assessment of stage of change: |___|
1 – Yes
2 – No
3 – No assessment