Adolescent Addiction Recovery Intake Worksheet
Adolescent Information
Full Name
Date of Birth
Gender
School
Address
Phone
Email
Parent/Guardian Information
Parent/Guardian Name
Relationship
Phone
Email
Address (if different)
Referral Information
Referral Source
Reason for Referral
Substance Use History
List Substances Used
Age at First Use
Pattern/Frequency of Use
Previous Treatment(s) (if any)
Mental & Physical Health
Mental Health Diagnoses/Concerns
Medical History (Conditions/Allergies)
Current Medications
Social & Educational Information
Family Dynamics
School Performance/Challenges
Peer Relationships
Legal Issues (if any)
Goals for Recovery
Short-term and Long-term Goals
Additional Notes