SALCE- Pre-Evaluation Forms - Denise O’Doherty

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Your Name*

First Last

Your Address:*

Street Address Address Line 2 City State ZIP Code

Driver’s License Number:*

Date of Birth:*

Cell Phone Number:*

Work phone:*

Your email:*

Is this report going to your Attorney?*

Yes

Is this report going to your Probation officer?*

Yes

Attorney Name:

First Last

Attorney Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Attorney Phone:

Attorney Fax Number:

Attorney Email:

Probation Officer Name:

Probation Officer Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Probation Officer Phone:

Probation Officer Fax:

Probation Officer Email:

Date of this Current Arrest:*

Court date (if you know it):

Why were you arrested? What happened?*

Using the spaces below, please list any prior alcohol/drug related or any other arrests

Arrest #1 When:

Arrest #1 For What offense?

Arrest #1 What type of treatment / rehab did you have at that time? Where?

Arrest #2 When:

Arrest #2 For What offense?

Arrest #2 What type of treatment / rehab did you have at that time? Where?

Arrest #3 When:

Arrest #3 For what offense?

Arrest #3 What type of treatment / rehab did you have at that time? Where?

Do you feel alcohol or drug use has been problematic for you at any time in your life?

How often do you drink?

On average, how many days a week do you drink?

On average, how many days a month do you drink?

When you drink, what’s the maximum number of drinks you have had?

What’s the average number of drinks you have when you drink?

How often do you use drugs (not prescribed by an MD)

What drugs have you used in the last year?

Are you aware that alcoholism and depression are hereditary?

Who in your family has had a problem with alcohol / drugs?

Is anyone in your family in a 12-step program?

How old were you when you first had a drink?

How old were you when you first used a recreational drug?

When in your life did you drink the most?

When in your life did you use recreational drug the most?

Where do you work?

What do you do?

How long have you been there?

If in School, where do you attend?

What is your highest level of education?

Who do you live with?

Do you have any children? (ages)

Do you have any health problems?

Have you ever been depressed? If so, when?

Are you on medication now for any physical / mental health issues?

Yes

Please list your medications:

Do you presently attend individual, couples, family, or group therapy? If so, Where?

Do you attend AA or any other 12 Step Meetings presently? If so, how often and where?

Do you have a Sponsor?

Have you ever attended AA or any other 12 Step Program?

Current Significant Stressors: (other than this arrest)

Significant Stressor 1

Significant Stressor 2

Significant Stressor 3

What do you do to manage your stress?

What do you do for exercise?

What do you do to relax?

Do you have any hobbies?

Do you belong to any social, professional, civic organizations?

Signature

I give my permission for Denise O’Doherty LPC, LMFT to release results of this SALCE EVALUATION and her summary, either directly, verbally, via fax, email or post office mail, to my attorney and /or probation officer.

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