Substance Abuse Counseling Case Assessment
Client Information
Client Name
Date of Assessment
Date of Birth
Gender
Contact Information
Presenting Problem
Description
Substance Use History
Substances Used
Frequency/Quantity
Age of First Use
Last Use
Previous Treatment (if any)
Medical & Mental Health History
Medical Conditions
Mental Health History
Social & Family History
Living Situation
Family Relationships
Support System
Employment/School
Legal History
Past/Current Legal Issues
Assessment Summary
Summary/Clinical Impressions
Treatment Recommendations
Recommendations
Counselor Information
Counselor Name
Date