Substance Abuse Case Management Intake Form
Client Information
Full Name
Date of Birth
Gender
Male
Female
Non-binary
Other
Phone Number
Address
Referral/Intake Details
Date of Intake
Referred By
Reason for Referral
Substance Use History
Primary Substance Used
Other Substances Used
Duration of Use
Last Use Date
Medical & Mental Health
Medical Conditions
Mental Health History
Current Medications
Legal History
Legal Issues (if any)
Probation/Parole Status
Social & Family History
Living Situation
Family Support
Employment/School Status
Goals & Needs
Client's Stated Goals
Identified Needs
Case Manager Use Only
Assessment Notes
Initial Plan