Court-Mandated Substance Abuse Screening Form
I. Client Information
Full Name
Date of Birth
Phone Number
Email Address
Address
II. Court Information
Court Case Number
Presiding Judge
Offense(s)
Probation/Parole Officer
III. Screening Information
Date of Screening
Screening Location
Screened By
IV. Substance Use History
Substances Used (check all that apply)
Alcohol
Marijuana
Cocaine
Prescription Drugs
Opioids
Other
If "Other," please specify
Duration/Frequency of Use
Previous Treatment
V. Screening Outcome
Screening Result
No Treatment Recommended
Outpatient Treatment Recommended
Inpatient Treatment Recommended
Further Evaluation Needed
Comments/Notes
Screening Provider Signature
Date