Form field inventory

10 documents, generated directly from the live form definitions.

Client Information

Source: SAP Registration packet, page 1 · PDF: rebuilt layout

Note: Preferred contact number is a choice list (original: tick beside the number).

Text	Name	Required
Date	DOB	Required
Single choice	GenderM · F
Text	SS#
Single choice	Relationship StatusMarried · Single · Separated · Divorced · Widowed · Partnership
Text	Home Address	Required
Text	City	Required
Text	State	Required
Text	Zip	Required
Text	Phone (h)
Text	Phone (w)
Text	Phone (cell)
Single choice	Please ✔ the number at which you prefer to be contacted.Home (h) · Work (w) · Cell
Single choice	May I text message you?Yes · No
Text	email
Text	Employed by
Text	Job Title
Text	Time Employed with Company
Single choice	Do you have any medical conditions which might require emergency aid?Yes · No	Required
Long answer	Please list serious medical conditions
Text	Name of emergency contact	Required
Text	Phone #'s	Required
Single choice	May we contact this person in the case of an emergency?Yes · No	Required
Table	Other Members in HouseholdName · Relationship · Age
Long answer	Reason for seeking counseling?	Required

Consent for Evaluation and Short-Term Counseling

Source: SAP Registration packet, page 2 · PDF: rebuilt layout

Document text	11 paragraph(s)
Document text	ACKNOWLEDGEMENT 1 paragraph(s)
Signature(s)	Client, Parent or Guardian (optional)

Fees & Billing Policy – Substance Abuse Professional Services

Source: SAP Registration packet, page 3 · PDF: rebuilt layout

Document text	2 paragraph(s)
Document text	PAYMENT Due: 2 paragraph(s)
Text	Insurance Company
Text	Mental Health Benefits Phone #
Text	Subscriber
Text	ID #
Document text	ASSIGNMENT OF BENEFITS 1 paragraph(s)
Signature(s)	Client

Authorization to Use or Disclose Protected Health Information

Source: SAP Registration packet, page 4 · PDF: rebuilt layout

Text	Patient Name	Required
Text	SS #
Date	Date of Birth	Required
Document text	1 paragraph(s)
Long answer	Company officials (Human Resources, Safety Officials)
Checkboxes	Such disclosure shall include the following specific types of information and communication unless NA placed in front:Initial Assessment · Treatment Plan · Session Progress Notes · Diagnostic Report · Psychosocial Assessment · CD/SAP Assessment · Progress Report · Aftercare Plan · Attendance Report · Discharge Summary · Psychological Testing · Telephone Consultations · Correspondence · Billing Information · Drug/Alcohol Test Results
Document text	2 paragraph(s)
Single choice	This authorization, which provides consent, expires:One year from the date of last clinical contact, or · When the following event happens	Required
Document text	6 paragraph(s)
Signature(s)	Patient, Patient Representative (optional)

Notice of Privacy Practices

Source: SAP Registration packet, pages 6–7 · PDF: rebuilt layout

Note: Title “Notice of Privacy Practices” added as heading (source page shows letterhead only).

Document text

31 paragraph(s)

Drug Screening Questionnaire (DAST)

Source: DAST/MAST/BAM packet, page 1 · PDF: rebuilt layout

Note: The clinician scoring key printed on the source page is not shown to clients and no score is calculated.

Text	Patient name	Required
Date	Date of birth	Required
Checkboxes	Which recreational drugs have you used in the past year? (Check all that apply)methamphetamines (speed, crystal) · cocaine · cannabis (marijuana, pot) · narcotics (heroin, oxycodone, methadone, etc.) · inhalants (paint thinner, aerosol, glue) · hallucinogens (LSD, mushrooms) · tranquilizers (valium) · other
Single choice	How often have you used these drugs?Monthly or less · Weekly · Daily or almost daily
Yes / No	Have you used drugs other than those required for medical reasons?	Required
Yes / No	Do you abuse (use) more than one drug at a time?	Required
Yes / No	Are you unable to stop using drugs when you want to?	Required
Yes / No	Have you ever had blackouts or flashbacks as a result of drug use?	Required
Yes / No	Do you ever feel bad or guilty about your drug use?	Required
Yes / No	Does your spouse (or parents) ever complain about your involvement with drugs?	Required
Yes / No	Have you neglected your family because of your use of drugs?	Required
Yes / No	Have you engaged in illegal activities in order to obtain drugs?	Required
Yes / No	Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?	Required
Yes / No	Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?	Required
Yes / No	Do you inject drugs?	Required
Yes / No	Have you ever been in treatment for a drug problem?	Required

Questionnaire About Drinking (Alcohol) Habits (MAST)

Source: DAST/MAST/BAM packet, pages 2–3 · PDF: rebuilt layout

Note: A client name field was added so the downloaded PDF can be identified (the source page has no name line).

Document text	Directions: 1 paragraph(s)
Text	Your name (so the PDF can be identified)	Required
Yes / No	Do you feel you are a normal (social) drinker?	Required
Yes / No	Have you ever awakened in the morning after some drinking the night before and found that you could not remember a part of that evening?	Required
Yes / No	Does your spouse (or parents) ever worry or complain about your drinking?	Required
Yes / No	Can you stop drinking without a struggle after one or two drinks?	Required
Yes / No	Do you ever feel bad about your drinking?	Required
Yes / No	Do friends and relatives think you are a normal drinker?	Required
Yes / No	Do you ever try to limit your drinking to certain times of the day or to certain places?	Required
Yes / No	Are you always able to stop drinking when you want to?	Required
Yes / No	Have you ever attended a meeting of Alcoholics Anonymous (AA)?	Required
Yes / No	Have you ever gotten in fights while drinking?	Required
Yes / No	Has drinking ever created problems with you and your spouse (or parents)?	Required
Yes / No	Has your spouse (or other family member) ever gone to anyone for help about your drinking?	Required
Yes / No	Have you ever lost a friend or girlfriends or boyfriends because of your drinking?	Required
Yes / No	Have you ever gotten into trouble at work because of your drinking?	Required
Yes / No	Have you ever lost a job because of your drinking?	Required
Yes / No	Have you ever neglected your obligations, your family or your work for 2 or more days in a row because you were drinking?	Required
Yes / No	Do you ever drink before noon?	Required
Yes / No	Have you ever been told you have liver trouble?	Required
Yes / No	Have you ever had delirium tremens (DT's) severe shaking, heard voices or seen things that were not there after heavy drinking?	Required
Yes / No	Have you ever gone to anyone for help about your drinking?	Required
Yes / No	Have you ever been in a hospital because of drinking?	Required
Yes / No	Have you ever been in a psychiatric or mental or on a psychiatric ward of a general hospital where drinking was part of the problem?	Required
Yes / No	Have you ever been seen at a psychiatric or mental health clinic, or gone to a doctor, social worker, or clergyman for help with an emotional problem in which drinking played a part?	Required
Yes / No	Have you ever been arrested, even for a few hours, because of drunk behavior?	Required
Yes / No	Have you ever been arrested for drunk driving or driving after drinking?	Required

Brief Addiction Monitor (BAM)

Source: DAST/MAST/BAM packet, pages 4–6 · PDF: rebuilt layout

Note: Handwritten notes on the source scan (e.g. “lifestyle”, “or Counseling”, “treatment”) were not reproduced.

Document text	1 paragraph(s)
Text	Name	Required
Text	Last 4
Date	Date	Required
Single choice	1. In the past 30 days, would you say your physical health has been?Poor · Fair · Good · Very Good · Excellent	Required
Single choice	2. In the past 30 days, how many nights did you have trouble falling asleep or staying asleep?0 nights · 1-3 nights · 4-8 nights · 9-15 nights · 16-30 nights	Required
Single choice	3. In the past 30 days, how many days have you felt depressed, anxious, angry, or very upset?0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	4. In the past 30 days, how many days did you drink ANY alcohol?0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	5. In the past 30 days, how many days did you have at least 5 drinks (if you are a man) or 4 drinks (if you are a woman)? [One drink is a shot of hard liquor (1.5 oz.), a 12-oz can/bottle of beer, or a 5 oz glass of wine.]0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	6. In the past 30 days, how many days did you use any illegal/street drugs or abuse any prescription medications?0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	7a. Marijuana (cannabis, pot, weed)0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	7b. Sedatives/Tranquilizers (e.g., "benzos," Valium, Xanax, Ativan, Ambien, "Barbs," Phenobarbital, downers, etc.)0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	7c. Cocaine/Crack0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	7d. Other Stimulants (e.g., amphetamines, methamphetamine, Dexedrine, Ritalin, Adderall, "speed," "crystal meth", "ice," "crank," etc.)0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	7e. Opiates (e.g., Heroin, Morphine, Dilaudid, Demerol, Oxycontin, "oxcy," codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	7f. Other drugs (e.g., steroids non-prescription sleep or diet pills, Benadryl, ephedra, other over-the-counter/unknown meds, etc.)0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	8. In the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs? (circle your response)Not at all Bothered · Slightly Bothered · Moderately Bothered · Considerably Bothered · Extremely Bothered	Required
Single choice	9. How confident are you in your ability to be completely abstinent (clean) from alcohol and drugs in the next 30 days? (circle your response)Not at all Confident · Slightly Confident · Moderately Confident · Considerably Confident · Extremely Confident	Required
Single choice	10. In the past 30 days, how many days did you attend self-help meetings like AA or NA to support your recovery?0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	11. In the past 30 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky "people, places, or things")?0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	12. Does your religion or spirituality help support your recovery? (circle your response)Not at all Helpful · Slightly Helpful · Moderately Helpful · Considerably Helpful · Extremely Helpful	Required
Single choice	13. In the past 30 days, how many days did you spend much of the time at work or school, in programs to help your recovery, or doing volunteer work?0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	14. Do you have enough income (from legal sources) to pay for necessities such as housing, transportation, food, and clothing for yourself and your dependents? (circle your response)No · Yes	Required
Single choice	15. In the past 30 days, how much have you been bothered by arguments or problems getting along with any family members or friends? (circle your response)Not at all Bothered · Slightly Bothered · Moderately Bothered · Considerably Bothered · Extremely Bothered	Required
Single choice	16. In the past 30 days, how many days were you in contact or spend time with any family members or friends who are supportive of your recovery?0 days · 1-3 days · 4-8 days · 9-15 days · 16-30 days	Required
Single choice	17. How satisfied are you with your progress toward achieving your recovery goals? (circle your response)Not at all Satisfied · Slightly Satisfied · Moderately Satisfied · Considerably Satisfied · Extremely Satisfied	Required

Agreement for Reinstatement Return-to-Work Procedures — DISA Contractor Consortium (DCC)

Source: SAP Registration packet, page 5 (DISA Global Solutions form) · PDF: fields placed on original page

Note: Return to Duty Manager signature is left blank for the manager to sign.

Text	Name	Required
Date	Date	Required
Text	Social Security Number	Required
Document text	1 paragraph(s)
Text	I, (your full name)	Required
Document text	7 paragraph(s)
Signature(s)	Employee

12 Step Meeting Log - AA, NA, CA, PA

Source: AA Attendance Log (blank) · PDF: rebuilt layout

Note: Leader's Initials column is never filled digitally. Print the PDF and ask each meeting leader to initial it in person.

Text	Month/Year	Required
Table	MeetingsDate · Time · Meeting Name/Location · Meeting Type · Leader's Initials · What you learned	Required
Document text	1 paragraph(s)
Signature(s)	Client