Internet Addiction Recovery Program APPLICATION ... - HEAL

More documents

Recommendations

Info

Internet Addiction Recovery Program PRESENTING CONCERN/PROBLEM Provided by ________________________________________ Briefly list your concerns in order of priority. 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ 4. _________________________________________________________________________________________________________ Any previous involvement in counseling or treatment Yes No When was the problem first noted, and by whom (Include age/grade, sudden or gradual, noticed personally or brought to attention by someone else) ____________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ How often does the problem occur, and in what settings ____________________________________________________________ ___________________________________________________________________________________________________________ What is the intensity/severity of the behavior _____________________________________________________________________ ___________________________________________________________________________________________________________ What are the typical antecedents to the behavior _________________________________________________________________ __________________________________________________________________________________________________________ Is the behavior usually in response to some event or provocation (e.g., person, setting, situation, time of day, event), or does it appear to happen for no reason ____________________________________________________________________________________ __________________________________________________________________________________________________________ What is the variability in the behavior across time, settings, people, etc. (e.g., preset, cyclic) ______________________________ __________________________________________________________________________________________________________ What typically happens after the behavior occurs ________________________________________________________________ What are the typical consequences ____________________________________________________________________________ What have parents tried to do to modify consequences and what have been the results _________________________________ __________________________________________________________________________________________________________ How consistent have parents’ reactions been ___________________________________________________________________ What effect does the problem have on others; what is the level and type of impairment associated with the problem _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ What are short‐term and long‐term consequences _______________________________________________________________ _________________________________________________________________________________________________________ Page | 4 reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 restart@netaddictionrecovery.com | www.netaddictionrecovery.com
Internet Addiction Recovery Program PARTICIPANT HISTORY Please read the following questions pertaining to the participant and mark the checkbox with those to which you would respond “yes” and explain. EDUCATIONAL HISTORY Last Grade Completed 7 th 8 th 9 th 10 th 11 th 12 th College Freshman Sophomore Junior Senior Grad School Has participant earned his/her high school diploma or GED Yes No _____________________________________________________________ Currently attending school Yes No if yes, where ___________________________________________________________________________ Are these concerns interfering with participant’s ability to attend school Yes No ___________________________________________________ Is this problem interfering with academic performance Yes No __________________________________________________________________ MENTAL/BEHAVIORAL HEALTH HISTORY: Diagnosis How is this being managed Diagnosis How is this being managed ADD/ADHD ______________________________________ Depression _____________________________________ Asbergers ______________________________________ Anxiety _____________________________________ Autism ______________________________________ PTSD _____________________________________ ODD ______________________________________ Bi‐polar _____________________________________ OCD ______________________________________ _____________ _____________________________________ Describe other mental/emotional concerns not listed above ________________________________________________________________ Is there a history of being hospitalized for mental health reasons _________________________________________________________________ Is there a history of mental health issues in the family Please explain ______________________________________________________________ CURRENT/PAST HISTORY OF SUBSTANCE USE: Substance used Date of last use Frequency per week Substance used Date of last use Frequency per week Tobacco _______________ ____ Packs per day Speed ______________ _______________ Chew _______________ _______________ Ecstasy ______________ _______________ Marijuana _______________ _______________ Cocaine ______________ _______________ Alcohol _______________ _______________ Crack ______________ _______________ Energy Drinks _______________ _______________ Speed ______________ _______________ Caffeine _______________ _______________ Heroin ______________ _______________ _____________ _______________ _______________ Meth ______________ _______________ _____________ _______________ _______________ _____________ ______________ _______________ Any illegal substances use not listed above _______________________________________________________________________________ Prescription drug use (not prescribed to student) If so, what _______________________________________________________________ Is there a history of alcohol or drug problems in the family Please explain__________________________________________________________ ______________________________________________________________________________________________________________________ Page | 5 reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 restart@netaddictionrecovery.com | www.netaddictionrecovery.com
Page 1 and 2: Internet Addiction Recovery Program
Page 3: Internet Addiction Recovery Program
Page 17 and 18: PRESCRIPTION MEDICATION FORM Intern
Page 19 and 20: RECOVERY AGREEMENT (continued) AGRE
Page 25: Internet Addiction Recovery Program

Internet Addiction Recovery Program APPLICATION ... - HEAL

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?