Applicant Name ___________________________________________________________________________
(Last, First, Middle Initial)
Date of Birth___________/_________ /___________
(Mo/Day/Year)
Substance-Related and Addictive Disorders Current Evaluation Form
(Confidential)
The individual listed above has applied to serve as a Peace Corps Volunteer and has reported a history of a substance-related and/or an addictive disorder. The mental health provider who has oversight and management of the applicant’s treatment or has access to the applicant’s mental health records should complete this form. If you do not have access to appropriate records, please indicate this on the form.
Note to the Mental Health Provider: Please be candid when answering the questions below. During Peace Corps service a Volunteer may be placed in a community that is very isolated and remote, with the potential for a history of high crime, history of violence, current extreme poverty, and/or inequitable treatment of members of the population. . There may also be limited access to Alcohol Anonymous (AA), Narcotics Anonymous (NA), Western-trained mental health professionals and little support for existing or new mental health symptoms. Please take these factors into consideration when answering the questions below. This form will also be considered “incomplete” and returned to the applicant if all questions are not answered.
This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq. It will be used primarily for the purpose of determining your eligibility for Peace Corps service and, if you are invited to service as a Peace Corps Volunteer, for the purpose of providing you with medical care during your Peace Corps service. Your disclosure of this information is voluntary; however, your failure to provide this information or failure to disclose relevant information may result in the rejection of your application to become a Peace Corps Volunteer.
This information may be used for the purposes described in the Privacy Act, 5 U.S.C. 552a, including the routine uses listed in the Peace Corps’ System of Records. Among other uses, this information may be used by those Peace Corps staff members who have a need for such information in the performance of their duties. It may also be disclosed to the Office of Workers’ Compensation Programs in the Department of Labor in connection with claims under the Federal Employees’ Compensation Act and, when necessary, to a physician, psychiatrist, clinical psychologist, licensed clinical social worker or other medical personnel treating you or involved in your treatment or care. A full list of routine uses for this information can be found on the Peace Corps website at http://multimedia.peacecorps.gov/multimedia/pdf/policies/systemofrecords.pdf.
Public reporting burden for this collection of information is estimated to average four hours and 25 minutes per applicant and three hours per substance abuse professional per response. This estimate includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th Street, NW, Washington, DC, 20526 ATTN: PRA (0420-0550). Do not return the complete from to this address.
Mental Health Provider’s Name and Degree (Print): _________________________________________________________
Date: __________________________ License No.: __________________________ State: __________________________
Address: ________________________________________________________ Phone: _____________________________
Certified Substance-Related and Addictive Disorder Counselor? Yes No
Dates of Evaluation Sessions
Note to the provider: Please complete as many evaluation sessions (one, two, or three visits) as you feel is necessary to evaluate the current identified concern(s). Three visits are not required if one or two sessions are sufficient time to complete an assessment.
a.)______________________________ b.) ______________________________ c.) ______________________________
Prior to this evaluation, have you treated this applicant for a condition? Yes No
Have you received reports of prior treatment for this applicant? Yes No
If marked “No” or documentation is insufficient, then please be sure to inquire fully about the applicant’s health and treatment history.
Please provide the following information based on your treatment and/or clinical assessment of this applicant. Please be as detailed as possible. *Where applicable, please have the applicant include information about arrests or other disciplinary actions due to alcohol or drug use.*
A. Past & Current Clinical Disorders (Formerly Axes I, II, and III in DSM-IV-TR)
Please indicate date given and date remitted, if applicable. Please also indicate if no current diagnosis is present or if diagnosis is ongoing.
Mental Disorders:
Diagnosis |
Date Given |
Date Remitted |
Ongoing (Yes/No) |
|
|
|
Yes No |
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|
Yes No |
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|
Yes No |
|
|
|
Yes No |
General Medical Disorders:
Diagnosis |
Date Given |
Date Remitted |
Ongoing (Yes/No) |
|
|
|
Yes No |
|
|
|
Yes No |
|
|
|
Yes No |
|
|
|
Yes No |
B. Psychotropic Medications (Current & Previous)
*** If possible, please have the prescribing clinician complete this section. ***
Medication and Dosage |
Start Date |
End Date |
Response to Medication |
Recommended Monitoring Plan |
|
|
|
|
|
|
|
|
|
|
Signature: ________________________________________________________ Date: _____________________________
Name & Title (Print): __________________________________________________________________________________
C. History of Symptoms/Behaviors of Concern
Please be as specific and comprehensive as possible. If more space is needed, please use blank page or back of this form.
Substance(s) of choice: ___________________________________________________________________________________________________
___________________________________________________________________________________________________
“Yes” Requires Comment(s) |
|
Comment(s) |
At what age did the applicant begin use? |
|
_________________________ (in years) |
What was the frequency and extent of use? *Report frequency and extent. |
|
_________________________ (times per day/week) _________________________ (amount/quantity) _________________________ (for how long) |
History of blackouts or loss of consciousness/memory? *Include dates and circumstances. |
Yes No |
|
History of negative psychosocial repercussions (primary support group, legal, work, economic/housing) related to alcohol/drug use? *Provide dates and circumstances. |
Yes No |
|
History of physical problems related to alcohol/drug use? *Include dates, diagnosis, and details of treatment. |
Yes No |
|
History of use of AA/NA meetings or longer-term supports to maintain sobriety/abstinence? *If yes, what is the longest length of time the applicant has gone without a meeting and what was the result? |
Yes No |
|
D. Clinical Assessment of Current Functioning and Substance/Alcohol Use
Current Assessment of Use |
Comments |
Is the applicant currently sober/abstinent? *If yes, include length of sobriety/abstinence. |
Yes No _________ Months _________ Years |
What is the applicant’s current sobriety plan? |
Not Applicable; individual is not currently sober/abstinent (Please describe amount and frequency of current use): _________________________________________________________ Applicable (Please Describe): _______________________________ |
Is the applicant reliant on AA/NA (or other longer-term support programs) to remain sober/abstinent? *List the average number of meetings per week/month. |
Yes No Applicant attends __________ meetings each ___________________ |
If the above answer is “Yes,” then what is the longest time the applicant has gone without a meeting and what was the result? |
|
E. Past & Current Mental Health/Substance-Related Hospitalizations & Treatment
Past Treatment? Yes No Date(s): ________________________ *From intake to discharge If “Yes,” please describe context/reasons. _______________________________ |
Current Treatment? Yes No Date: __________________________ *Intake If “Yes,” please describe context/reasons. _______________________________ |
Hospitalizations? Yes No Date(s): ________________________ *From intake to discharge If “Yes,” please describe context/reasons. _______________________________ |
F. Past & Current Risk Assessment/Information
Suicide Attempt? Yes No Date(s): _____________ If “Yes,” please describe context(s) and outcome(s). _____________________ Risk of Recurrence (Check One): None/Unlikely Possible/Likely Describe: _____________________ _____________________ |
Suicidal Gesture? Yes No Date(s): _____________ If “Yes,” please describe context(s) and outcome(s). _____________________ _____________________ Risk of Recurrence (Check One): None/Unlikely Possible/Likely Describe: _____________________ _____________________ |
Suicidal Ideation? Yes No Date(s): _____________ If “Yes,” please describe context(s) and outcome(s). _____________________ Risk of Recurrence (Check One): None/Unlikely Possible/Likely Describe: _____________________ _____________________ |
Self-Injurious Behaviors? Yes No Date(s): _____________ *From start to remittance If “Yes,” please describe context(s) and outcome(s). _____________________ Risk of Recurrence (Check One): None/Unlikely Possible/Likely Describe: _____________________ I am unable to assess this |
AUDIT or Other Tests/Measures Administered:
Please attach pertinent reports or summaries, if any
1. ____________________________________________________________________________________________
2. ____________________________________________________________________________________________
To the best of your ability, describe the applicant’s ego strength, emotional stability, and flexibility:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
To the best of your ability, describe the applicant’s coping strategies: ___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
To the best of your ability, describe the applicant’s overall functioning (interpersonal and work) and prognosis based on your clinical observations:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
What is the applicant’s plan for sobriety/abstinence while serving in the Peace Corps?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
To the best of your ability, rate and describe the applicant’s risk of relapse in a stressful overseas environment (characterized by isolation, lack of structure, and limited social supports):
High/Likely Possible Low/Unlikely
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
Peace Corps – Alcohol/Substance Abuse Current Evaluation Form PC‐262-6 (Previous editions are obsolete) Page 5 of 6
H. Recommendations & Follow Up
What specific recommendations for substance-related support do you have regarding the management of this applicant’s condition over the next three years? All recommendations will help determine the best placement for the Peace Corps applicant. ___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Any other comments or concerns related to the information provided on this form or regarding this applicant? ___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
I certify this information is, in my opinion, an accurate representation of the baseline status of this substance-related condition for the applicant listed above.
Mental Health Provider’s Signature: _____________________________________________________________________
Date: __________________________
Peace Corps – Alcohol/Substance Abuse Current Evaluation Form PC‐262-6 (Previous editions are obsolete) Page 6 of 6
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Eckard, Elizabeth |
File Modified | 0000-00-00 |
File Created | 2021-01-20 |