Substance Abuse Counseling Intake Form
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Phone Number
Address
Email
Emergency Contact
Name
Relationship
Phone Number
Substance Use History
Substances Used
Frequency of Use
Age of First Use
Last Use
Previous Treatment (if any)
Mental & Physical Health
Current/Past Mental Health Issues
Current/Past Physical Health Issues
Additional Information
What are your goals for counseling?
Anything else you'd like to share?