Care Management Enrollment – Alchemy Consulting

1. What is your name?

2. What is the best number to reach you at?

3. Can we leave a message at this number identifying who we are?
YesNo
4. What is your email address?

5. What is your relationship with your loved one that we are intervening on?

6. How were you referred to our team?

7. Goals for loved one while in Care Management?

8. How will loved one benefit from Care Management?

9. Why are you reaching out?

Loved One

10. What is the name of your loved one that we are intervening on?

11. Does your loved one have a nickname?

12. What is you loved one's date of birth?

13. What gender does your loved one identify as?

14. What is your loved one's home address?

15. Who does your loved one live with?

Children

16. Does your loved one have children?
YesNo

16.1. Do the children live in the same household as your loved one? Please describe the living situation.

Relationships

17. What is your loved one's sexual orientation?

18. What is your loved one's marital status?

18.1. Is your loved one's partner a positive influence?

18.2. Is it possible that your loved one is using with their partner?
YesNo

19. Does anyone else in your family struggle with substance abuse
YesNo
20. Tell us about your loved one's current support system

Drug Abuse

21. Is your loved one abusing drugs?
YesNo

21.1. Describe their progression of drug abuse

21.2. What do you believe your loved one's longest amount of sober time has been?

21.3. What is the primary drug of choice that you know your loved one is using?

21.3.1. How is your loved one administering the drug?

21.3.2. How much do you suspect your loved one is using?

21.3.3. How often do you believe your loved one using this drug?

21.4. What is the secondary drug of choice that you know your loved one is using?

21.4.1. How is your loved one administering the drug?

21.4.2. How much do you suspect your loved one is using?

21.4.3. How often do you believe your loved one using this drug?

21.5. What is the third drug of choice that you know your loved one is using?

21.5.1. How is your loved one administering the drug?

21.5.2. How much do you suspect your loved one is using?

21.5.3. How often do you believe your loved one using this drug?

21.6. What is the fourth drug of choice that you know your loved one is using?

21.6.1. How is your loved one administering the drug?

21.6.2. How much do you suspect your loved one is using?

21.6.3. How often do you believe your loved one using this drug?

Mental Health

22. Does your loved one have a mental health diagnosis?
YesNo

22.1 Mental Health Diagnosis

23. If there is no mental health diagnosis, do you have any concerns or suspicions about their mental health?

24. What have you experienced that has you concerned?

25. Has your loved one experienced Hallucinations?
YesNo

25.1. When was then last time your loved one experienced hallucinations?

25.2. How often has your loved one experienced hallucinations?

25.3. When your loved one experienced hallucination were they under the influence?

26. Has your loved one ever heard voices? If so, please explain
YesNo

26.1. How often has your loved one reported hearing voices?

27. Has your loved one ever believed that they were being spied on or followed?
YesNo

27.1. How often has your loved one reported being spied on or followed?

Violence

28. Does your loved one have a history of violence towards others?
YesNo

28.1. Can you please describe the most recent violent event?

29. Does your loved one have any formal fight training such as martial arts or boxing?

30. Does your loved one own a gun?
YesNo
31. Has your loved one ever been arrested?
YesNo

31.1. What was your loved one arrested for?

31.2. When was your loved one arrested?

31.3. Has your loved one been convicted of a crime?
YesNo
31.4. What was your loved one convicted of?

31.5. Is your loved one currently on parole or probation?
YesNo
31.6. Does your loved one have a current pending legal issue?

31.7. Does your loved one have a scheduled court date?
YesNo
31.8. When is the court date?

31.9. Does your loved one have any warrants?
YesNo
31.10. What are the warrants for?

Self Harm

32. Does your loved one have a history of self harm? (example: cutting, burning, pulling out hair)
YesNo

32.1. How has your loved one harmed themselves?

32.2. Has your loved one ever received medical attention due to their self harm?
YesNo
32.3. What medical attention did your loved one receive?

Suicidality

33. Has your loved one ever attempted to take their own life?
YesNo

33.1. How did your loved one attempt to take his/her own life?

33.2. Was your loved one hospitalized after he/she attempted suicide?
YesNo
33.3. How many times has your loved one attempted to take their own life?

34. Does your loved one ever have thoughts or made statements about taking their own life?
YesNo

34.1. What has your loved one said or done that leads you to believe that they could be a danger to themselves?

34.2. How recent were these suicidal statements made?

35. Has your loved one ever made statements about harming someone else?
YesNo

35.1. Describe these statements and when they were made

Trauma

36. Has your loved one experienced trauma?
YesNo

36.1. What trauma has your loved one experienced?

36.2. How recent was the event?

36.3. Does your loved one ever experience flashbacks or nightmares?

36.4. Has your loved one been diagnosed with PTSD?
YesNo

Eating Disorder

37. Has your loved one ever struggled with an eating disorder?
YesNo

37.1. What type of eating disorder did they struggle with?

37.2. Approximately what has been their highest weight?

37.3. Approximately what has been their lowest weight?

37.4. Is your loved one active in their eating disorder now?
YesNo
37.5. How long has your loved one struggled with an eating disorder?

38. Has your loved one ever used a substance to control their weight?
YesNo

38.1. What substance did they use to control their weight?

39. Has your loved one ever been hospitalized with an eating disorder?
YesNo

Process Addictions

40. Do you feel like your loved one may struggle with sexual addiction?
YesNo

40.1. What are their acting out behaviors? (example masturbation, prostitution, porn, multiple partners)?

40.2. How often do you believe your loved one is engaging in these actions?

40.3. Does your love one have any past or present legal issues due to their sexual acting out behaviors?
YesNo

40.3.1. Describe your loved one's legal issues

40.4. Do you believe your loved one is engaging in behaviors that they could be arrested for?
YesNo

40.4.1. What are those behaviors?

41. Do you feel your loved one may struggle with a gambling addiction?
YesNo

41.1. Please describe your loved ones actions that lead you to believe they have a gambling addiction

41.2. Does your loved one use drug s or alcohol while gambling?
YesNo

41.2.1. What substance does your loved one use?

41.2. What has your loved one lost due to gambling?

Health

42. Is it possible that your loved one is pregnant?
YesNo

43. Has your loved one every experienced a stroke?
YesNo

44. Has your loved one ever suffered from a head injury where they lost consciousness?
YesNo

44.1. When was this and how was it treated?

45. Has your loved one ever experienced seizures or convulsions?
YesNo

45.1. How often and how recently did this happen?

45.2. Is your loved one taking medication for a seizure disorder? What is the medication called?

46. Please list any surgeries your loved one has had over the last 5 years

47. Has your loved one been hospitalized in the last 6 months for a medical condition?

48. When was the last time your loved one saw a physician?

Medication

49. Is your loved one taking any over the counter medication?

50. Is your loved one taking any prescribed medication?
YesNo

50.1. Medication 1

50.2. What is this medication taken for?

50.3. Medication 2

50.4. What is this medication taken for?

50.5. Medication 3

50.6. What is this medication taken for?

50.7. Medication 4

50.8. What is this medication taken for?

51. Is there any medication that your loved one has been prescribed but refuses to take? Please tell us what medication your loved one should be taking and why they are refusing to take it.

Treatment History

52. Has your loved one ever been to treatment before?
YesNo

52.1. What was treated?

52.1.1. Month and Year

52.1.2. What level of care?

52.2. What else was treated?

52.2.1. Month and Year

52.2.2. What level of care?

52.3. What else was treated?

52.3.1. Month and Year

52.3.2. What level of care?

52.4. What else was treated?

52.4.1. Month and Year

52.4.2. What level of care?

52.5. Describe your loved one's experience in treatment

52.6. What has your loved one's experience been with the 12 steps?

Current Treatment Provider

53. Name of your loved one's Psychiatrist

54. Phone or Email

55. Name of your loved one's Psychologist

56. Phone or Email

57. Name of your loved one's Therapist

58. Phone or Email

59. Name of your loved one's Internist

60. Phone or Email

61. Is there anything that you would like us to know about your loved one's current treatment provider?

Personal Information

62. Does your loved one have a valid ID?
YesNo
63. Is your loved one currently employed?
YesNo
64. Where does your loved one work?

Financially Responsible Party

65. Name of the financially responsible party

66. Phone number

67. Email address

68. Address

69. Loved one's relationship to the financially responsible party?

Care Management

online enrollment form

Care Management

Enrollment

get started now

Online Enrollment Form

Loved One

Children

Relationships

Drug Abuse

Mental Health

Violence

Self Harm

Suicidality

Trauma

Eating Disorder

Process Addictions

Health

Medication

Treatment History

Current Treatment Provider

Personal Information

Financially Responsible Party

Don’t wait for tomorrow to come.
Take action & get help today.

recovery is

possible.

Care Management

online enrollment form

Care Management

Enrollment

get started now

Online Enrollment Form

Loved One

Children

Relationships

Drug Abuse

Mental Health

Violence

Self Harm

Suicidality

Trauma

Eating Disorder

Process Addictions

Health

Medication

Treatment History

Current Treatment Provider

Personal Information

Financially Responsible Party

Don’t wait for tomorrow to come. Take action & get help today.

recovery is

possible.

Don’t wait for tomorrow to come.
Take action & get help today.