Substance Abuse Program Initial Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Phone Number
Email
Address
Emergency Contact
Name
Relationship
Phone
Referral Information
Referred By
Reason for Referral
Substance Use History
Substances Used
Frequency of Use
Age at First Use
Date of Last Use
Prior Treatment History
Medical & Mental Health
Medical Conditions
Current Medications
Mental Health History
Legal & Social Information
Legal Issues
Current Living Situation
Employment Status
Additional Comments