Faith-Informed Substance Abuse Intake Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Contact Number
Email Address
Substance Use History
Primary Substance of Concern
How long have you been using?
Frequency of use
Previous Treatment History
Faith Background
Faith Tradition / Denomination
Current Spiritual Practices
Role of Faith in Recovery
Support System
Who is part of your support network?
Involvement in Faith Community
Additional Information
What are your goals for treatment?
Concerns or Questions