Download DA Form 8000, also known as an ASAP Triage Instrument. This form is used to gather information with regard to personnel who may be struggling with addiction. The same would apply for personnel, soldiers or otherwise, who may be struggling as well with forms of mental illness or who may be contemplating suicide. It’s simply an emergency information tool for therapists in the military to assist in proper treatment for emotional health.
How To Fill-In
Step 1 – Fill in blocks 1 through 7 –
- 1. Date (yyyy/mm/dd format)
- 2. Name of Commander
- 3. Sex
- 4. Unit Telephone Number
- 5. Your Reason For Coming In
- 6. Date Of Last Alcohol Use (yyyy/mm/dd format) – How Much? (alcohol was consumed )
- 7. Date Of Last Drug Use (yyyy/mm/dd format) – How Much? (drugs were consumed)
Step 2 – Answer the following:
- 9. Have You Been Enrolled In An Alcohol Or Other Drug Program? If Yes, Please Give Dates Enrolled And Brief Summary Of Why You Were Enrolled
Step 3 – Section 10. and A through D
- 10. What Alcoholic Beverages Or Other Drugs Do You Presently Use?
- a. Which Ones Are Causing You The Most Problems?
- b. How Is It Affecting Your Work?
- c. How Is It Affecting Your Family Life?
- d. How Is It Affecting Your Personal Life?
Step 4 – Patient Identification: For typed or written entries provide the following information:
- Name – Last, First, MI format
- Date(s) hospitalization- yyyy/mm/dd format)
- Hospital or Medical Facility
Step 5 – Answer questions 11 through 14:
11. Do You Presently Need To Continue To Drink Or Take Other Drugs So You Can Avoid Having Shakes, Depression Or Other Uncomfortable Feelings?
- 12. Do You Need To Drink Or Take Other Drugs To Cope? (yes or no – if yes explain)
- 13.a. Are You Contemplating Suicide? (yes or no – if yes explain)
- b. Have You Ever Contemplated Suicide In The Past (yes or no – If yes explain)
- 14. Are There Any Other Comments You Wish To Make? (if so write in the box provided)
The final section is for the counselor’s use only*
- 1. Patient Status (check routine or acute)
- 2. Immediate Service Provided
- 4. Counselor’s Signature