Juvenile Justice Substance Screening Questionnaire

Identifying Information

Full Name Date of Birth Sex Case/ID Number Date of Screening

1. Have you ever used alcohol? Yes No

2. Have you ever used marijuana or cannabis? Yes No

3. Have you used any other drugs (prescription or street drugs)? Yes No

4. Has your use of alcohol or drugs ever caused problems (at home, school, or with the law)? Yes No

5. Has anyone ever expressed concern about your alcohol or drug use? Yes No

If yes to any above, please specify details (substance, frequency, last use, etc.) Notes/Comments

Name Title/Role