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KIDSZ PARADISE INC.

10 HAMILTON BLVD NW STE E

CARTERSVILLE, GA 30120

678-719-8140 Phone

678-451-6341 Cell

Email: lbatts@kidszparadise.com

Board Certified Alcohol and drug counselor II

Credentialed by: ADACBGA/ IC&RC

Addiction Severity Assessment

Client Name:*

Client Address:*

Client Phone: *

Client DOB:*

Interview Date:*

Time in: *

Time Out:*

Needed by department of pre trial services:*

Email:*

Level of Care: *

Location of Service: *

Client Reference #: *

Date of Admission: *

Units: *


PRESENTING SITUATION*

MEDICAL STATUS*

EMPLOYMENT/SUPPORT STATUS*

DRUG/ALCOHOL USE*

LEGAL STATUS *

FAMILY HISTORY*

FAMILY/SOCIAL RELATIONSHIPS*

PSYCHIATRIC STATUS*

INTERVIEWERS ASSESSMENT*

RECOMMENDATION FOR TREATMENT *

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