Substance Abuse & Mental Health Evaluation
Client Name
Date of Birth
Evaluation Date
Referral Source
Presenting Problem
Substance Use History
Substances Used (include frequency, amount, duration):
Date of Last Use
History of Withdrawal Symptoms
Mental Health History
Previous Mental Health Diagnoses
Previous Treatment (outpatient/inpatient, duration, response)
Current Medications
Psychosocial History
Medical History
Legal Issues
Family/Social Support
Employment/Education History
Mental Status Exam
Appearance/Behavior
Mood/Affect
Thought Process/Content
Cognition/Orientation
Suicidal/Homicidal Risk
Assessment & Recommendations
Summary/Clinical Impressions
Diagnosis (DSM-5)
Recommendations (treatment, referrals, follow-up)
Evaluator Name & Credentials
Signature
Date