Substance Abuse Treatment Prequalification Form
Full Name
Date of Birth
Phone Number
Email Address
Type of Substance(s) Used
How long have you been using these substance(s)?
Are you currently seeking treatment voluntarily?
Yes
No
Do you have a history of previous treatment(s) for substance abuse?
Yes
No
If yes, please provide details (when, where, outcome, etc.)
Are you currently experiencing withdrawal symptoms?
Yes
No
Do you have any current medical or mental health conditions?
What are your goals for treatment?
Additional Comments