Telehealth Substance Use Assessment
Patient Information
Full Name
Date of Birth
Date of Assessment
Presenting Concerns
Reason for Assessment
Substance Use History
Substances Used (select all that apply)
Alcohol
Tobacco
Marijuana
Cocaine
Opioids
Stimulants
Hallucinogens
Prescription Medications (nonmedical use)
Other
Frequency and Amount
Duration of Use
Last Use
Impact of Substance Use
Physical Health Impact
Mental Health Impact
Social/Occupational Impact
Risk Assessment
Withdrawal Symptoms
Overdose Risk
Current Mental Status
Previous Treatment History
Previous Treatment or Interventions
Response to Previous Treatment
Readiness for Change
Current Motivation
Not ready
Considering change
Ready to change
Maintenance
Barriers to Change
Summary & Recommendations
Summary
Recommendations