Court-Ordered Substance Abuse Evaluation
Personal Information
Full Name
Date of Birth
Address
Phone Number
Case Number
Referral Information
Referring Court/Agency
Offense
Date of Referral
Substance Use History
Substances Used
Frequency/Duration of Use
Date of Last Use
Medical & Mental Health History
Medical History
Mental Health History
Social & Legal History
Employment/Education Status
Legal History
Assessment Summary
Findings
Recommendations
Evaluator Information
Evaluator Name
Evaluator Title
Date of Evaluation