Substance Use Dual Diagnosis Intake Form
Client Information
Full Name
Date of Birth
Contact Number
Email
Address
Referral Information
Referred By
Date of Referral
Presenting Concerns
Describe the main concerns and reason for seeking help
Substance Use History
Substances Used (Select all that apply):
Alcohol
Cannabis
Opioids
Stimulants
Hallucinogens
Other
Frequency and Amount of Use
Age of First Use
Periods of Abstinence
Mental Health History
Mental Health Diagnoses (if any)
Current Symptoms
Previous Treatments or Hospitalizations
Medical History
Current Medical Conditions
Current Medications
Social and Family History
Living Situation
Family Psychiatric/Substance Use History
Support System
Risk Assessment
Any current thoughts of self-harm or harm to others?
Yes
No
If yes, please elaborate