Plan Your Recovery
Counseling
314-467-8393
call/text
Psychiatry
314-222-5830
call/text
Therapy
Psychiatry
Patients
Conditions
Continuing Ed
← ASI-5
Full Interview
General Information
1
General Information
2
Medical Status
3
Employment / Support
4
Alcohol & Drugs
5
Legal Status
6
Family History
7
Family & Social
8
Psychiatric
9
Results
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G1
ID Number
G4
Date of Admission (mm/dd/yyyy)
G5
Date of Interview (mm/dd/yyyy)
G6
Time Begun (24-hr, HH:MM)
G7
Time Ended (HH:MM)
:
G8
Class
—
1 — Intake
2 — Follow-up
G9
Contact Code
—
1 — In person
2 — Telephone
G10
Gender
—
1 — Male
2 — Female
G99
Treatment Episode Number
G11
Interviewer Code Number
G12
Special
—
1 — Patient terminated
2 — Patient refused
3 — Patient unable to respond
G14
How long at current address?
yrs
mos
G15
Residence owned by you or family? (0=No, 1=Yes)
G16
Date of Birth (mm/dd/yyyy)
G17
Race
—
1 — White (not Hisp)
2 — Black (not Hisp)
3 — American Indian
4 — Alaskan Native
5 — Asian/Pacific
6 — Hispanic-Mexican
7 — Hispanic-Puerto Rican
8 — Hispanic-Cuban
9 — Unknown
G18
Religious Preference
—
1 — Protestant
2 — Catholic
3 — Jewish
4 — Islamic
5 — Other
6 — None
G19
Controlled environment past 30 days?
—
1 — No (not in controlled environment)
2 — Jail/prison
3 — Alcohol or drug tx
4 — Medical tx
5 — Psychiatric tx
6 — Other
General Information Comments
Include the question number with your notes.
Include the question number with your notes.