Substance Abuse & Mental Health Assessment Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Non-binary
Other
Prefer not to say
Contact Number
Address
Substance Use History
Substances Used (select all that apply)
Alcohol
Tobacco
Marijuana
Cocaine
Opioids
Stimulants
Hallucinogens
Benzodiazepines
Other
Frequency of Use
Age of First Use
Date of Most Recent Use
Pattern of Use / Comments
Mental Health History
Past or Current Mental Health Diagnoses
Current Symptoms
Psychiatric Hospitalizations (if any)
Current Medications
Past/Current Therapy or Counseling
Risk Assessment
Thoughts of Suicide or Self-Harm
Never
Occasionally
Frequently
Currently
Thoughts of Violence Toward Others
Never
Occasionally
Frequently
Currently
Social & Functional Status
Support System / Relationships
Work / School Status
Legal Problems
Housing Situation
Additional Notes