Assessment Application - Homer - Set Free Alaska - Alcohol and Drug Treatment Alaska

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Set Free Assessment Form - Homer

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Client Profile
Name*
First Last
Client Gender*
- Male
- Female
If female, maiden name required.*
Mailing Address*
Street Address City State ZIP Code
Email
Enter Email Confirm Email
Main Contact Phone*
Other Phone
Date of Birth*
MM
DD
YYYY
Social Security Number
SACC Client Id Number (if known)

Demographics
Races(s): Check all that apply*
- American Indian
- Asian
- Caucasian
- Native Hawaiian
- Pacific Islander
- Alaska Native
- Aleut
- Athabascan
- Haida
- Tlingit
- Tsimshian
- Yupik
- Other Alaska Native
- Other
- Unknown
Ethnicity: Check One*
- Not Spanish / Hispanic / Latino
- Chicano
- Cuban
- Hispanic
- Mexican American
- Puerto Rican
- Spanish / Hispanic / Latino
- Unknown
English Fluency: Check One*
- Excellent
- Good
- Moderate
- Poor
- Not at all
- No response
Education: Check one*
- If K-11, state how many years in the box below.
- GED
- High School Diploma
- Vocational Training
- Special Ed Classes
- Bachelors Degree
- Graduate Work (no degree)
- Masters Degree
- Doctorate Degree
- Post Secondary 1 yr
- Post Secondary 2 yrs
- Post Secondary 3 yrs
- Post Secondary 4+ yrs (no degree)
- Unknown
Highest Level Education Completed*
Veteran Status: Check one*
- Never in Military
- Reserves / National Guard - Combat
- Reserves - No Combat
- Military Dependant
- Active Duty - Combat
- Active Duty - No Combat
- Retired From Military
- Verteran Other Eras
- Vietnam Vet - Combat
- Vietnam Vet - No Combat
- Unknown
Special Needs: Check all that apply*
- None
- No Response
- Dev Disabled
- Major Difficulty in Ambulating
- Moderate to Severe Medical Problems
- Severe Hearing Loss or Deaf
- Traumatic Brain Injury
- Visual Impairment or Blind
- Unknown

Intake Information
Initial Contact: Check one*
- Phone
- Drop In (Orientation)
- Hospital / On Call Intervention
- Community Service Patrol
- By Appointment
- Other
City / Village: Check one*
- Anchorage
- Eagle River
- Wasilla
- Palmer
- Other location outside of Anchorage bowl area (specify below)
Source of Referral: Check one*
- ASAP
- Federal Probation
- Office of Children's Services
- Department of Corrections / Jail
- Correctional Agency (Probation of Parole)
- Court - Civil Proceedings
- Court - Criminal Proceedings
- Individual / Self Referral
- Crisis / Respite Care
- Alaska Native Hospital
- Detox or Residential Program
- API
- Assisted Living Facility
- Attourney
- Developmental Disabilities Residential Program
- Developmental Disabilities Program
- Drug Program, Employer (EAP)
- Halfway House
- Nursing Home
- Other Mental Health (not including psychiatrist)
- Other
Only Required if Female: Pregnant?
- Yes
- No
If Yes: Due Date
Date Format: MM slash DD slash YYYY
Injection Drug User (within the last 12 months)*
- Yes
- No
- Unknown
Primary Presenting Problem:*
- Alcohol & Drugs
- Alcohol
- Drugs
Secondary: (Specify From List Below. If none put N/A)*
Tertiary: (Specify From List Below. If none put N/A)*
(Alcohol & Drugs Alcohol Only; Drugs Only; Suicide attempt/threat; Child abuse victim; Sexual abuse victim; Domestic violence victim; Eating disorder; Thought disorder; Depression; Social/interpersonal (not family); Coping with daily roles/activities; Marital; Family (non marital); Medical/somatic; Psychological/emotional; Financial; Poverty; Child abuse perpetrator; Sexual abuse perpetrator; DV perpetrator; None; Other; Unknown)
Presenting Problem(s) in clients own words: Why is the client seeking services?*
Special Initiative: Check all that apply*
- Theraputic Courts
- Women With Children
- Aquired Brain Disorders
- Adult - Organic Disorder without SED
- Adult - Severe & Persistent Mental Illness
- Adult - Severe Emotional Disturbance
- Fetal Alcohol Syndrome
- HIV
- Methadone
- Persistant & Disabling Personality Disorder
- Psychiatric Emergency Services
- Traumatic Brain Injury
- None
Consent*
By signing and submitting this form, I am giving consent to Set Free Alaska to enter my identifying information on Alaska’s Automated Information Management System (AKAIMS). Furthermore, I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the agencies identified above may not condition my treatment on whether I sign a consent form, but that in certain circumstances I may be denied treatment if I do not sign a consent form.
Signature*
Email
This field is for validation purposes and should be left unchanged.

Set Free Alaska Inc. – Mat-Su

Office - 907-373-4732

Fax - 907-746-4749

PO BOX 876741

Wasilla, AK 99687

M-T-W-F 9 AM-5 PM | TH 11 AM-5PM

Keep In Touch

Set Free Alaska Inc. – Homer

907 235-4732

907 235-4733

1130 Ocean Drive Suite A

Homer, AK 99603

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Home
About
▲
Services
▲
Donations
Testimonies
Employment
Contact
▲
- Mat-Su Office 907-373-4732
- Homer Office 907-235-4732
Connect

Set Free Alaska

Phone 907-373-4732

Fax 907-746-4749