School Counselor Substance Abuse Intake Form

Full Name Date of Birth Grade Student ID Parent/Guardian Name Contact Number Date of Intake Referred By Reason for Referral Substances Used (Check all that apply) If Other, Please Specify Frequency of Use Duration of Use Physical Symptoms Observed Behavioral Concerns Observed Academic Impact Previous Counseling or Interventions? If Yes, Please Describe Family Situation / Support System Notes Recommended Actions / Referrals