Substance Abuse Intake Assessment

NAME:

DATE(S) OF ASSESSMENT:

DOB:

DATA SOURCES:

REASON FOR REFERRAL:

IDENTIFYING INFORMATION:

FAMILY HISTORY:

EDUCATIONAL AND VOCATIONAL BACKGROUND:

PREVIOUS MENTAL HEALTH TREATMENT (INCLUDING SUBSTANCE ABUSE TREATMENT):

Make sure to include a summary of previous diagnosis and response to treatment.

AVAILABLE SUPPORTS AND RISKS:

ACCESS TO COMMUNITY RESOURCES:

MENTAL STATUS AND GENERAL OBSERVATIONS:

RECOMMENDED SCREENING AND ASSESSMENT TOOLS:

Justify your recommendations.

SUMMARY: Make sure to describe how the client’s background and current mental status may affect their current behaviors and treatment outcomes.

SUGGESTED DIAGNOSES: