Military Veteran Substance Abuse Intake Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Phone
Email
Address
Military Service Information
Branch of Service
Years Served
Discharge Type
Honorable
General
Other than Honorable
Dishonorable
Uncharacterized
Combat Experience
Yes
No
Substance Use History
Substances Used
Frequency of Use
Duration of Use
Date Last Used
Previous Treatment Attempts
Yes
No
If yes, please describe
Mental Health History
Diagnosed Mental Health Conditions
Current Medications
History of Suicidal Thoughts or Attempts
Yes
No
Emergency Contact
Name
Phone
Relationship