Referral to Ft.

Lyon Please fax to 719-456-0109

Contact Name: ___________________________________________
Phone: __________________ Email Address: ___________________________
Referral Agency: ___________________________
Todays Date: _________

Client Name: ________________________________________________
DOB: ___________ Gender: ___________
Have you served in the Armed Forces: Yes___ No___


Brief description of current situation, including current housing status:



Is Detox needed? Yes____ No____ If yes, what is the Detox plan?

CCH Only Review Chart YES ___ NO ___ `

Previous Substance Abuse Treatment? Yes____ No____ Drug use? Yes___ No___ Which
drug(s)__________________________________________________________________

If yes, briefly describe (when, where): _______________________________

Mental Health Diagnosis? Yes____ No____

If yes, current diagnosis: _________________________________________

Where are they receiving treatment? _____________________________________

Current Prescribed Medications:_________________________________________

Do they have a current supply of medications? Yes____ No____ How Many Days? ____



Medical Issues: ______________________________________________________

Currently receiving treatment? Yes____ No____

If yes, where at? _______________________________________________

Current Prescribed Medications:



Benefits: Medicaid____ Medicare____ SSI____ SSDI____ AND____ OAP____ VA____

Do they have verification of benefits? Yes____ No____

Currently on parole or probation? Yes_____ No____ If yes, please provide a release of
information for us to speak with the probation officer

Socrates completed? Yes____ No____

Re-Integration Plan: Yes___ No___ If yes, completed and attached to referral____________


Emergency contact for client: Name____________________________

Phone:____________________________

Highest level of education completed:____________________________

Authorization to Request / Release Information



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Name:_______________________________________________________________
PLACE CLIENT LABEL HERE
Address: _____________________________________________________________

Date of Birth: __________________________ SS#____________________________MR#___________________________


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I authorize:

Facility:

Address: ______________________________________

______________________________________________

Phone# _______________________________________

Fax # _________________________________________

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I authorize:

Facility: CCH/Ft Lyon

Address: ___________________________________

___________________________________________

Phone# _____________________________________

Fax#_______________________________________

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Medical Information
Psychiatric Conditions
AIDS/HIV testing
Mental Health Treatment/Information
Substance Treatment Information
STDs
Other (specify) _________________________


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Continuation of Care
Insurance
Legal
Workers Compensation
Personal/other (specify) _________________________


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Release:
All of my records
Records limited to: (mo./yr. mo./yr.)________________________

A
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If the information to be released pertains to the diagnosis and treatment of alcoholism and/or drug abuse, I understand that Federal
Law 42 CFR Part 2 protects the confidentiality of the information. The Federal rules prohibits you from making any further
disclosure of this information unless further disclosure is expressly permitted by the written consent of person to whom it pertains or
as otherwise permitted by 42CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for
this purpose.
I certify that this request has been made voluntarily. I understand this consent will expire upon________, or if left blank, in one (1)
year. I hereby release the provider/agency from any liability that may result from furnishing the information requested as authorized
in the release. I understand that I may revoke this authorization at any time (except to the extent that the action has been taken to
comply with it); I must do so in writing to the facility Privacy Officer or his/her designee. If I have authorized the disclosure of my
health information to someone who is not legally required to keep it private, it may be re-disclosed and may no longer be protected
by the HIPAA Privacy Rule. I MAY REFUSE TO SIGN THIS AUTHORIZATION. A copy of this authorization is to be considered
as valid as the original.
I understand that the information released may include a diagnosis or reference to the following condition (s): behavioral health
services/psychiatric care; acquired immune deficiency syndrome (AIDS), human immunodeficiency virus (HIV), or drug and/or
alcohol abuse.

S
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By signing the Authorization I understand that treatment, payment, enrollment or eligibility for benefits may not be conditioned on
signing the Authorization.

_________________________________________Relationship: ________________________________ Date:_______________
Client, (Parent or Guardian if client is a minor).

_________________________________________________Date:________________________
Witness G:/fitzsimons/HIPAA/4/13


Ft. Lyon Referral Packet - Last Updated 10/1/2013 3 of 17

Authorization to Request / Release Information



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Name:_______________________________________________________________
PLACE CLIENT LABEL HERE
Address: _____________________________________________________________

Date of Birth: __________________________ SS#____________________________MR#___________________________


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I authorize:

Facility: CCH/FtLyon

Address: ______________________________________

______________________________________________

Phone# _______________________________________

Fax # _________________________________________

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I authorize:

Facility: ___________________________________

Address: ___________________________________

___________________________________________

Phone# _____________________________________

Fax#_______________________________________

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Medical Information
Psychiatric Conditions
AIDS/HIV testing
Mental Health Treatment/Information
Substance Treatment Information
STDs
Other (specify) _________________________


P
u
r
p
o
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o
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R
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Continuation of Care
Insurance
Legal
Workers Compensation
Personal/other (specify) _________________________


T
i
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e


S
p
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Release:
All of my records
Records limited to: (mo./yr. mo./yr.)________________________

A
u
t
h
o
r
i
z
a
t
i
o
n


If the information to be released pertains to the diagnosis and treatment of alcoholism and/or drug abuse, I understand that Federal
Law 42 CFR Part 2 protects the confidentiality of the information. The Federal rules prohibits you from making any further
disclosure of this information unless further disclosure is expressly permitted by the written consent of person to whom it pertains or
as otherwise permitted by 42CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for
this purpose.
I certify that this request has been made voluntarily. I understand this consent will expire upon________, or if left blank, in one (1)
year. I hereby release the provider/agency from any liability that may result from furnishing the information requested as authorized
in the release. I understand that I may revoke this authorization at any time (except to the extent that the action has been taken to
comply with it); I must do so in writing to the facility Privacy Officer or his/her designee. If I have authorized the disclosure of my
health information to someone who is not legally required to keep it private, it may be re-disclosed and may no longer be protected
by the HIPAA Privacy Rule. I MAY REFUSE TO SIGN THIS AUTHORIZATION. A copy of this authorization is to be considered
as valid as the original.
I understand that the information released may include a diagnosis or reference to the following condition (s): behavioral health
services/psychiatric care; acquired immune deficiency syndrome (AIDS), human immunodeficiency virus (HIV), or drug and/or
alcohol abuse.

S
i
g
n
a
t
u
r
e

By signing the Authorization I understand that treatment, payment, enrollment or eligibility for benefits may not be conditioned on
signing the Authorization.

_________________________________________Relationship: ________________________________ Date:_______________
Client, (Parent or Guardian if client is a minor).

_________________________________________________Date:________________________
Witness G:/fitzsimons/HIPAA/4/13


Ft. Lyon Referral Packet - Last Updated 10/1/2013 4 of 17
Rental Services, Inc.
(303) 420-1212 (800) 628-6414 FAX (303) 420-1477 FAX (800) 296-9902
______________________________________________________________________________________

Applicant Screening Request
Administrative Information
This information is required to process this application.

Rental Services Customer: Colorado Coalition for the Homeless
Department: Ft Lyon
Contact Name: Lynn Rider Title: Clinical Director Alternate contact: James Ginsburg, Director/Ft Lyon

Phone: 719-662-1108 (or 720-933-5644) Fax: 719-456-0109 Attention: Lynn Rider

Type of report requested please check one:
[] Eviction and Credit Only

[] Eviction and Credit Plus National Criminal Check

[X] National criminal only

[X] CO criminal courts

[X] CBI



Applicant Screening Request Form
Please print clearly. All fields must be completed.


Name: _____________________________________________________ DOB: ______________ SS#: _________________


Address: ________________________________________________City _______________State _________________Zip:__________


Applicants Contact #: _____________________________________________ Alt #: _______________________________


Co-Applicant: _______________________________________________ DOB: ______________ SS#: _________________


Address: ________________________________________________City ________________State ________________Zip: __________


Co-Applicants Contact #: _____________________________________________ Alt #: ____________________________

I declare that the statements above are true and correct. I authorize verification of my references and credit as they relate to my tenancy
AND to future rent collections.

Date________________ Signed____________________________________ Co-Signed_____________________________
Ft. Lyon Referral Packet - Last Updated 10/1/2013 5 of 17
Reintegration Plan

Name:____________________________________ Date:__________________

Anticipated length of stay at Fort Lyon:



What are your plans upon return to your community in the following areas:

Housing:


Relapse Prevention:
Substance use:

Mental Health:

Medical:


Support System:
Ft. Lyon Referral Packet - Last Updated 10/1/2013 6 of 17
Version 8
SOCRATES
The Stages of Change Readiness and Treatment Eagerness Scale
SOCRATES is an experimental instrument designed to assess readiness for change in alcohol abusers. The instrument
yields three factorially-derived scale scores: Recognition (Re), Ambivalence (Am), and Taking Steps (Ts). It is a public
domain instrument and may be used without special permission.
Answers are to be recorded directly on the questionnaire form. Scoring is accomplished by transferring to the
SOCRATES Scoring Form the numbers circled by the respondent for each item. The sum of each column yields the
three scale scores. Data entry screens and scoring routines are available.
These instruments are provided for research uses only. Version 8 is a reduced 19-item scale based on factor analyses
with prior versions. The shorter form was developed using the items that most strongly marked each factor. The 19-item
scale scores are highly related to the longer (39 item) scale for Recognition (r = .96), Taking Steps (.94), and Ambivalence
(.88). We therefore currently recommend using the 19-item Version 8 instrument.
Psychometric analyses revealed the following psychometric characteristics of the 19-item SOCRATES:
Cronbach Test-retest Reliability
Alpha Intraclass Pearson
Ambivalence .60 - .88 .82 .83
Recognition .85 - .95 .88 .94
Taking Steps .83 - .96 .91 .93
Various other forms of the SOCRATES have been developed. These will be migrated into shorter 8.0 versions as
psychometric studies are completed. They are:
8D 19-item drug/alcohol questionnaire for clients
7A-SO-M 32-item alcohol questionnaire for significant others of males
7A-SO-F 32-item alcohol questionnaire for SOs of females
7D-SO-F 32-item drug/alcohol questionnaire for SOs of females
7D-SO-M 32-item drug/alcohol questionnaire for SOs of males
The parallel SO forms are designed to assess the motivation for change of significant others (not collateral estimates of
clients' motivation). The SO forms lack a Maintenance scale, and therefore are 32 items in length.
Prochaska and DiClemente have developed a more general stages of change measure known as the University of Rhode
Island Change Assessment (URICA). The SOCRATES differs from the URICA in that SOCRATES poses questions
specifically about alcohol or other drug use, whereas URICA asks about the client's problem and change in a more
general manner.
Source Citation:
Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers' motivation for change: The Stages of Change Readiness
and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors 10, 81-89.
Ft. Lyon Referral Packet - Last Updated 10/1/2013 7 of 17
CASAA Research Division*
8/ 95
Personal Drinking Questionnaire
(SOCRATES 8A)
INSTRUCTIONS: Please read the following statements carefully. Each one describes a way that
you might (or might not) feel about your drinking. For each statement, circle one number from 1to 5, to
indicate how much you agree or disagree with it right now. Please circle one and only one number for
every statement.
NO!
Strongly
Disagree
No
Disagree
?
Undecided or
Unsure
Yes
Agree
YES!
Strongly Agree
1. I really want to make changes in my
drinking.
1 2 3 4 5
2. Sometimes I wonder if I am an alcoholic. 1 2 3 4 5
3. If I don't change my drinking soon, my
problems are going to get worse.
1 2 3 4 5
4. I have already started making some changes
in my drinking.
1 2 3 4 5
5. I was drinking too much at one time, but
I've managed to change my drinking.
1 2 3 4 5
6. Sometimes I wonder if my drinking is
hurting other people.
1 2 3 4 5
7. I am a problem drinker. 1 2 3 4 5
8. I'm not just thinking about changing my
drinking, I'm already doing something about
it.
1 2 3 4 5
9. I have already changed my drinking, and I
am looking for ways to keep from slipping
back to my old pattern.
1 2 3 4 5
10. I have serious problems with drinking. 1 2 3 4 5
Ft. Lyon Referral Packet - Last Updated 10/1/2013 8 of 17
NO!
Strongly
Disagree
No
Disagree
?
Undecided or
Unsure
Yes
Agree
YES!
Strongly Agree
11. Sometimes I wonder if I am in control of
my drinking.
1 2 3 4 5
12. My drinking is causing a lot of harm. 1 2 3 4 5
13. I am actively doing things now to cut down
or stop drinking.
1 2 3 4 5
14. I want help to keep from going back to the
drinking problems that I had before.
1 2 3 4 5
15. I know that I have a drinking problem.

1 2 3 4 5
16. There are times when I wonder if I drink
too much.
1 2 3 4 5
17. I am an alcoholic. 1 2 3 4 5
18. I am working hard to change my drinking. 1 2 3 4 5
19. I have made some changes in my drinking,
and I want some help to keep from going back
to the way I used to drink.
1 2 3 4 5
Ft. Lyon Referral Packet - Last Updated 10/1/2013 9 of 17
CASAA Research Division*
9/ 95
Personal Drug Use Questionnaire
(SOCRATES 8D)
INSTRUCTIONS: Please read the following statements carefully. Each one describes a way that
you might (or might not) feel about your drug use. For each statement, circle one number from 1to 5,
to indicate how much you agree or disagree with it right now. Please circle one and only one number
for every statement.
NO!
Strongly
Disagree
No
Disagree
?
Undecided or
Unsure
Yes
Agree
YES!
Strongly Agree
1. I really want to make changes in my use of
drugs.
1 2 3 4 5
2. Sometimes I wonder if I am an addict. 1 2 3 4 5
3. If I don't change my drug use soon, my
problems are going to get worse.
1 2 3 4 5
4. I have already started making some changes
in my use of drugs.
1 2 3 4 5
5. I was using drugs too much at one time, but
I've managed to change that.
1 2 3 4 5
6. Sometimes I wonder if my drug use is
hurting other people.
1 2 3 4 5
7. I have a drug problem.

1 2 3 4 5
8. I'm not just thinking about changing my
drug use, I'm already doing something about
it.
1 2 3 4 5
9. I have already changed my drug use, and I
am looking for ways to keep from slipping
back to my old pattern.
1 2 3 4 5
10. I have serious problems with drugs. 1 2 3 4 5
Ft. Lyon Referral Packet - Last Updated 10/1/2013 10 of 17
NO!
Strongly
Disagree
No
Disagree
?
Undecided or
Unsure
Yes
Agree
YES!
Strongly Agree
11. Sometimes I wonder if I am in control of
my drug use.
1 2 3 4 5
12. My drug use is causing a lot of harm. 1 2 3 4 5
13. I am actively doing things now to cut down
or stop my use of drugs.
1 2 3 4 5
14. I want help to keep from going back to the
drug problems that I had before.
1 2 3 4 5
15. I know that I have a drug problem.

1 2 3 4 5
16. There are times when I wonder if I use
drugs too much.
1 2 3 4 5
17. I am a drug addict. 1 2 3 4 5
18. I am working hard to change my drug use. 1 2 3 4 5
19. I have made some changes in my drug use,
and I want some help to keep from going back
to the way I used before.
1 2 3 4 5
Ft. Lyon Referral Packet - Last Updated 10/1/2013 11 of 17
SOCRATES Scoring Form - 19-Item Versions 8.0
Transfer the client's answers from questionnaire (see note below):
Recognition Ambivalence Taking Steps
1 ______ 2 ______
3 ______ 4 ______
5 ______
6 ______
7 ______ 8 ______
9 ______
10 ______ 11______
12 ______ 13 ______
14 ______
15 ______ 16 ______
17 ______ 18 ______
19 ______
TOTALS Re________ Am_______ Ts________
Possible
Range: 7-35 4-20 8-40
------------------------------------------------------------------------------------------------------------
Ft. Lyon Referral Packet - Last Updated 10/1/2013 12 of 17
SOCRATES Profile Sheet (19-Item Version 8A)
INSTRUCTIONS: From the SOCRATES Scoring Form (19-Item Version) transfer the total scale
scores into the empty boxes at the bottom of the Profile Sheet. Then for each scale, CIRCLE the
same value above it to determine the decile range.
DECILE
SCORES
Recognition Ambivalence Taking Steps
90 Very
High
19-20 39-40
80 18 37-38
70 High 35 17 36
60 34 16 34-35
50 Medium 32-33 15 33
40 31 14 31-32
30 Low 29-30 12-13 30
20 27-28 9-11 26-29
10 Very Low 7-26 4-8 8 - 25
RAW
SCORES
(from
Scoring
Sheet)
Re= Am= Ts=
These interpretive ranges are based on a sample of 1,726 adult men and women presenting for
treatment of alcohol problems through Project MATCH. Note that individual scores are
therefore being ranked as low, medium, or high relative to people already presenting for alcohol treatment.
Ft. Lyon Referral Packet - Last Updated 10/1/2013 13 of 17
Guidelines for Interpretation of SOCRATES-8 Scores
Using the SOCRATES Profile Sheet, circle the clients raw score within each of the three scale
columns. This provides information as to whether the clients scores are low, average, or high relative
to people already seeking treatment for alcohol problems. The following are provided as general guidelines
for interpretation of scores, but it is wise in an individual case also to examine individual item
responses for additional information.
RECOGNITION
HIGH scorers directly acknowledge that they are having problems related to their drinking,
tending to express a desire for change and to perceive that harm will continue if they do not
change.
LOW scorers deny that alcohol is causing them serious problems, reject diagnostic labels such
as problem drinker and alcoholic, and do not express a desire for change.
AMBIVALENCE
HIGH scorers say that they sometimes wonder if they are in control of their drinking, are
drinking too much, are hurting other people, and/ or are alcoholic. Thus a high score reflects
ambivalence or uncertainty. A high score here reflects some openness to reflection, as might
be particularly expected in the contemplation stage of change.
LOW scorers say that they do not wonder whether they drink too much, are in control, are
hurting others, or are alcoholic. Note that a person may score low on ambialence either
because they know their drinking is causing problems (high Recognition), or because they
know that they do not have drinking problems (low Recognition). Thus a low Ambivalence
score should be interpreted in relation to the Recognition score.
TAKING STEPS
HIGH scorers report that they are already doing things to make a positive change in their
drinking, and may have experienced some success in this regard. Change is underway, and
they may want help to persist or to prevent backsliding. A high score on this scale has been
found to be predictive of successful change.
LOW scorers report that they are not currently doing things to change their drinking, and have
not made such changes recently.
Ft. Lyon Referral Packet - Last Updated 10/1/2013 14 of 17
7 Document is in the public domain. Duplicating this material for personal or group use is permissible.
CO-OCCURRING DISORDERS PROGRAM: SCREENING AND ASSESSMENT
Mental Health Screening FormIII (MHSFIII)
Page 1 of 2
Instructions: In this program, we help people with all their problems, not just their addictions. This
commitment includes helping people with emotional problems. Our staff is ready to help you to deal with
any emotional problems you may have, but we can do this only if we are aware of the problems. Any
information you provide to us on this form will be kept in strict condence. It will not be released to any
outside person or agency without your permission. If you do not know how to answer these questions,
ask the staff member giving you this form for guidance. Please note, each item refers to your entire life
history, not just your current situation. This is why each question begins, Have you ever . . .
Please circle yes or no for each question.
1. Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor
about an emotional problem? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
2. Have you ever felt you needed help with your emotional problems, or have you had people
tell you that you should get help for your emotional problems?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
3. Have you ever been advised to take medication for anxiety, depression, hearing voices,
or for any other emotional problem? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
4. Have you ever been seen in a psychiatric emergency room or been hospitalized for
psychiatric reasons?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
5. Have you ever heard voices no one else could hear or seen objects or things which others
could not see?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
6. (a) Have you ever been depressed for weeks at a time, lost interest or pleasure in most
activities, had trouble concentrating and making decisions, or thought about killing yourself?. . . . . . Yes No
(b) Did you ever attempt to kill yourself?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
7. Have you ever had nightmares or ashbacks as a result of being involved in some
traumatic/terrible event? For example, warfare, gang ghts, re, domestic violence, rape,
incest, car accident, being shot or stabbed?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
8. Have you ever experienced any strong fears? For example, of heights, insects, animals,
dirt, attending social events, being in a crowd, being alone, being in places where it may be
hard to escape or get help? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
9. Have you ever given in to an aggressive urge or impulse, on more than one occasion, that
resulted in serious harm to others or led to the destruction of property? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
10. Have you ever felt that people had something against you, without them necessarily saying
so, or that someone or some group may be trying to inuence your thoughts or behavior?. . . . . . . . . Yes No
11. Have you ever experienced any emotional problems associated with your sexual interests,
your sexual activities, or your choice of sexual partner? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
12. Was there ever a period in your life when you spent a lot of time thinking and worrying about
gaining weight, becoming fat, or controlling your eating? For example, by repeatedly dieting
or fasting, engaging in much exercise to compensate for binge eating, taking enemas, or
forcing yourself to throw up? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
continued on other side
Ft. Lyon Referral Packet - Last Updated 10/1/2013 15 of 17
Page 2 of 2 Mental Health Screening FormIII (MHSFIII)
8 Document is in the public domain. Duplicating this material for personal or group use is permissible.
CO-OCCURRING DISORDERS PROGRAM: SCREENING AND ASSESSMENT
13. Have you ever had a period of time when you were so full of energy and your ideas came
very rapidly, when you talked nearly nonstop, when you moved quickly from one activity to
another, when you needed little sleep, and when you believed you could do almost anything? . . . . Yes No
14. Have you ever had spells or attacks when you suddenly felt anxious, frightened, or uneasy to
the extent that you began sweating, your heart began to beat rapidly, you were shaking or
trembling, your stomach was upset, or you felt dizzy or unsteady, as if you would faint? . . . . . . . . . . . Yes No
15. Have you ever had a persistent, lasting thought or impulse to do something over and over
that caused you considerable distress and interfered with normal routines, work, or social
relations? Examples would include repeatedly counting things, checking and rechecking
on things you had done, washing and rewashing your hands, praying, or maintaining a very
rigid schedule of daily activities from which you could not deviate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
16. Have you ever lost considerable sums of money through gambling or had problems at work,
in school, or with your family and friends as a result of your gambling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
17. Have you ever been told by teachers, guidance counselors, or others that you have a
special learning problem? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Print clients name: ____________________________________________________________________________________
Program to which client will be assigned: _________________________________________________________________
Name of admissions counselor: ______________________________________________________ Date: _________________
Reviewers comments: _________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
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The CAGE Questionnaire Adapted to Include
Drugs (CAGE-AID)

1. Have you felt you ought to cut down on your drinking or
drug use?
2. Have people annoyed you by criticizing your drinking or
drug use?
3. Have you felt bad or guilty about your drinking or drug
use?
4. Have you ever had a drink or used drugs first thing in the
morning to steady your nerves or to get rid of a hangover
(eye-opener)?


Score: __ /4

2/4 or greater = positive CAGE, further evaluation is indicated









Source: Reprinted with permission from the Wisconsin Medical J ournal. Brown, R.L., and
Rounds, L.A. Conjoint screening questionnaires for alcohol and drug abuse. Wisconsin
Medical J ournal 94:135-140, 1995.

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