Substance Abuse Counseling Consent and Intake Form

Personal Information

Full Name Date of Birth Phone Number Email Address Home Address

Emergency Contact

Name Relationship Phone Number

Substance Use Information

Substances Used (list all) Duration of Use Date/Time of Last Use Previous Treatment (if any) Describe Your Concerns / Goals

Medical History

Current Medical Conditions Current Medications Allergies

Consent

I hereby consent to participate in substance abuse counseling and authorize my counselor to provide necessary treatment. I understand that the information I provide is confidential and will only be shared as required by law or with my written consent.

Signature Date