Substance Abuse & Mental Health Dual Diagnosis Screening

Client Information

Full Name Date of Birth Screening Date

Have you ever used or misused any substances? (including alcohol, prescription drugs, illicit substances)

Yes No

If yes, please list substances used and frequency/duration:

Have you ever been diagnosed with a mental health condition?

Yes No

If yes, please specify diagnosis(es), and date(s) of diagnosis (if known):

Are you currently experiencing any of the following? (Select all that apply)

Anxiety Depression Psychosis Mood Swings Substance Withdrawal Symptoms Other

If other, please describe:

How have substance use and/or mental health concerns affected your daily life, relationships, work, or school?

Are you currently experiencing any of the following? (Check all that apply)

Thoughts of Self-Harm Thoughts of Harming Others None

If yes to any, please elaborate:

Screening Notes / Comments