Substance Abuse Assessment
Client Information
Name
Date of Birth
Gender
Female
Male
Other
Presenting Problem
Describe the main issue(s)
Substance Use History
Substances Used (List all)
Frequency of Use
Duration of Use
Date of Last Use
Impact & Consequences
Effects on Health, Family, Work, Legal
Treatment History
Prior Treatment(s)
Motivation & Goals
Motivation for Change
Treatment Goals