Substance Abuse Rehabilitation Intake Form
First Name
Last Name
Date of Birth
Gender
Male
Female
Non-binary
Prefer not to say
Address
Phone Number
Email
Emergency Contact Name
Emergency Contact Phone
Primary Substance of Abuse
Frequency of Use
Duration of Use (years/months)
Date of Last Use
Relevant Medical History
Relevant Mental Health History
Current Medications
Legal Issues (if any)
Treatment Goals