Name: ________________________________________
Date: _________________________________________
POINT VALUE
✦ = 3–6 points
✶ = 7–9 points
GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. ✦ Using the Internet or a local
telephone book, locate programs
within your community that can
help with the patient’s addiction,
such as Alcoholics Anonymous.
2. ✦ Make a list of the programs
available that can be of help for
the patient. On the list, include
telephone numbers and website
information.
3. ✦ Call or visit the website of the
selected programs to determine
meeting schedules and locations.
Include this information on the list
that will be given to the patient.
4. ✦ Obtain phone numbers and
information that will help the patient
with transportation, and include this
on the list of information which will
be given to the patient. *This could
include local public transportation,
taxi cab companies, and Uber.
5. ✦ Review the list of information with
the patient and ask if she has any
questions you could answer.
6. ✦ Provide the patient with your
name and the oce telephone
number. Encourage her to call you
with any questions.
7. ✶ Within 48 hours, place a follow-up
call to the patient to establish how
she is doing and if she has chosen
a meeting to attend. Inquire if
transportation has been arranged.
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