Adolescent Substance Use Risk Assessment Form
Personal Information
Full Name
Date of Birth
Age
Gender
Female
Male
Other
School/Institution
Substance Use History
What substances have you used in the past or currently use?
How often do you use any substance?
Never
Once or Twice
Monthly
Weekly
Daily
At what age did you first try any substance?
Risk Factors
Family history of substance use (parents, siblings, etc.)
Yes
No
Unknown
Do any of your close friends use substances?
Yes
No
Unknown
Has your academic performance changed recently?
Improved
No Change
Declined
Mental & Physical Health
Any mental health concerns (anxiety, depression, etc.)?
Any physical health issues?
Other Concerns or Remarks