Substance Abuse Counseling Intake Form
Client Information
Full Name
Date of Birth
Gender
Male
Female
Non-binary
Other
Prefer not to say
Phone Number
Email Address
Address
Emergency Contact
Name
Relationship
Phone Number
Referral Information
How did you hear about us?
Presenting Concerns
Please describe the main reason(s) for seeking counseling
Substance Use History
Substances Used (check all that apply)
Alcohol
Marijuana
Cocaine
Opioids
Prescription Drugs
Other
If other, please specify
How long have you been using substances?
Frequency of Use
Previous Treatment
Have you received previous substance abuse counseling/treatment?
Yes
No
If yes, please describe
Medical & Mental Health
Do you have any medical conditions?
Are you currently taking any medications?
Have you been diagnosed with a mental health condition?
Additional Information
Anything else you would like your counselor to know?