Substance Abuse Recovery Participant Risk Assessment
Participant Information
Name
Date
Date of Birth
Contact Information
Substance Use History
Substance(s) Used
Duration of Use
Date of Last Use
Current Risk Factors
Mental Health Status
Physical Health Status
Support Network
Housing Situation
Employment/Education
Legal Issues
Risk Assessment
Low
Medium
High
Reason(s) for Risk Level
Protective Factors
Action Plan / Recommendations
Assessor Name
Signature
Assessment Date