PRELIMINARY INFORMATION SHEET PAGE
For a first appointment at Step Ahead, Inc., you may contact us at anytime at our toll-free number, (877)-927-7837. However, it would be helpful if you would fill out the following Preliminary Information Sheet prior to setting up your first conference with Step Ahead staff. This will help us provide the help you need more efficiently. All information is confidential, for the use of Step Ahead counselors only.
When you have completed the information sheet and any attachments you may wish to include, you may mail or fax them to us for our review.
Step Ahead, Inc.,
54 Main Street, Suite 201
Succasunna, NJ 07876 &endash;
FAX: (973) 927-2250.
To email this questionnaire, copy the questionnaire in your web browser and paste it into your email program. Then fill out the answers and email to: email@example.com
We will notify you of their receipt and contact you about a first appointment. If you do not want to submit this sheet, fill it out and have it handy when you call to speak with us.
State _______ Zip Code _______________
Telephone Number(s): Home ____________________
Fax Number: _____________________
Email Address ____________________
Date of Birth _________ Marital Status ___________
Fill out the following profile sheets as appropriate, marking signs and symptoms with which you identify or have questions or concerns:
1. Signs and Symptoms of Substance Abuse (click here).
2. Signs and Symptoms of Family Members of Substance Abusers (click here).
If you are dealing with tobacco dependence issues, fill out the tobacco dependence questionnaire (click here).
Submit these sheets/questionnaires with your preliminary information sheet.
Treatment background information:
1.Have you received treatment for substance abuse/family issues/tobacco dependence in the past? Yes ___ No ___
2.If you have received treatment, please check which kind(s), when and where:
a. ____ Outpatient
b. ____ Intensive Outpatient
c. ____ Inpatient/Residential
d. ____ Detoxification
3. Have you been involved with 12-step fellowships (i.e. AA, NA, Nic-Anon, Al-Anon, etc.)? Yes ____ No ____
4. If you have been involved with 12-step fellowships, answer the following:
a. Do you currently attend meetings? Yes ___ No ___ Which program(s)
b. If not, how long did you attend meetings?
c. Which kind of meetings did you like best (Step, speaker, discussion, etc.)?
d. Which kind of meetings did you like least?
e. Did you have a sponsor? Yes ___ No ___ If yes, did you use him/her? ________
f. Have you ever applied the 12-step recovery principles to your daily life? _______
If so, with what result?
5. Have you affiliated yourself with recovery/self-help groups other than 12-step based ones? ___________ If so, which one(s)?
6. Do you have any history of diagnosed chronic medical conditions (e.g. diabetes, TB, clinical depression, asthma, etc.)? ____ If so, please list diagnosis:
7. Are you presently using any prescribed medications? If so, please list below:
8. Do you take any over-the-counter medications regularly? If so, please list below:
9. Do you have any legal problems? If so, list:
10. Have you tried to commit suicide in the last year?
you for helping us to meet your needs more
54 Main Street,
New Jersey 07876
Copyright © 2009 Step Ahead, Inc.
No portion of the web site may be duplicated without written permission.