Substance Abuse Evaluation
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Contact Information
Referral Information
Referral Source
Reason for Referral
Substance Use History
Substances Used (type, amount, frequency)
Age of First Use
Date of Last Use
Previous Treatment History
Medical and Psychiatric History
Medical Conditions
Psychiatric History
Social and Family History
Living Situation
Family Substance Use
Employment/Education Status
Legal History
Legal Issues/History
Assessment & Recommendations
Summary/Findings
Diagnosis
Recommendations