Substance Abuse Assessment Form
Full Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Contact Number
Emergency Contact
Substances Used (select all that apply)
Alcohol
Marijuana
Opioids
Cocaine
Stimulants
Benzodiazepines
Hallucinogens
Tobacco/Nicotine
Other
Frequency of Use
Duration of Use
What concerns do you have regarding your substance use?
Have you sought help for substance use before? If yes, please specify.
Additional Notes