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Addiction Questionaire

Adapted from the A.A. pamphlet, “Is A.A. For Me?”

Answer each of the following questions “yes” or “no”

“Yes” Answers will tell you if SOZO is right for you.

 

Have I tried to stop drinking/using for a week but could not do it?    Yes -or- No

Have I wished people would stop talking about my drinking/using?    Yes -or- No

Have I changed drinks/drugs to try to not get drunk or high?    Yes -or- No

Do I ever need a drink or drug to get going in the morning?    Yes -or- No

Do I envy people who can drink/use without getting into trouble?    Yes -or- No

Does my drinking/drugging cause problems at home?    Yes -or- No

Does my drinking/drugging cause problems with other people?    Yes -or- No

Do I try to get extra drinks?    Yes -or- No

Have I tried to stop drinking/drugging but still got drunk/high?    Yes -or- No

Have I missed work or cut school because of drinking/using?    Yes -or- No

Do I have blackouts – times I cannot remember?    Yes -or- No

Would my life be better if I quit drinking/drugging?    Yes -or- No

 

We Can Help!

Record Keeping

Each client’s records are kept in their personal and confidential three-ring binder, which is stored under lock and key. The information contained in this binder is organized under the following tabbed sections: Intake, Medical, Mentoring, Confidential, Staff Notes, Drug Screens and Misc. The documents contained in the Clients Chart/Binder are:

  • Screening Information
  • Resident’s Agreement to Comply with Program Guidelines
  • Admission Agreement
  • Informed Consent to Receive Recovery Services
  • Record of Drug Use History
  • Medical Admit Note
  • Addiction Severity Index
  • Drug Test Results
  • Personal Safety Plan
  • Authorization For Release of Information
  • Confidentiality of Client Records Statement
  • Client’s Rights to Privacy Statement
  • Visitation Guidelines
  • Emergency Plan
  • Mentoring Plan & Progress Report
  • Stages of Mentoring Development
  • Letter of Financial Agreement
  • Record of Client’s Payment of Fees
243 Nathan TerJessieville, AR 71949
Copyright © 2019 SOZO Recovery Centers Inc. All rights reserved.
Copyright © 2019 SOZO Recovery Centers Inc. All rights reserved.