Adolescent Substance Abuse Screening Form
Patient Information
Name
Date of Birth
Age
Screening Date
Provider/Clinician
Substance Use Screening
Have you ever used any of the following substances?
Alcohol
Tobacco
Cannabis
Prescription Drugs
Other
Age at first use (if any):
Frequency of use (please describe):
Typical amount used (please describe):
Risk Assessment
Any problems experienced as a result of substance use (school, family, legal, health, etc.):
Have you ever tried to cut down or stop using?
Yes
No
Have friends or family ever expressed concern about your use?
Yes
No
Have you ever used substances to cope with stress, anxiety, depression, or other feelings?
Yes
No
Additional Comments/Notes