Substance Abuse Assessment Intake Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Contact Phone
Address
Emergency Contact
Name
Relationship
Phone
Substance Use History
Primary Substance of Concern
Duration of Use
Date of Last Use
Frequency of Use
Other Substances Used
Treatment History
Previous Treatment (if any)
Current Medications
Mental & Physical Health
Mental Health Concerns/Diagnosis
Physical Health Issues
Other Information
Legal Issues (if any)
What are your goals for treatment?