Substance Abuse Intake FormDo you have any history of treatment from mental health professionals due to emotional or behavior problems? Yes No If yes, are you currently seeing a mental health professional? Yes No If yes, how many years total have you received mental health services? Have you ever been hospitalized for mental health reasons? Yes No Treatment history Month, Year, Agency name / Location # days Reason for service (Include DWI classes, detox, CD treatment, psychological/medical hospitalization in the last 6 months counseling/illness/accidents.)In your LIFETIME, which of the following substances have you ever used? Cocaine (coke, crack, etc.) Prescription stimulants (Ritalin, Adderall, etc.) Methamphetamine (speed, crystal, etc.) Inhalants (nitrous oxide, glue, etc.) Sedatives (Valium, sleeping pills, etc.) Hallucinogens (LSD, acid, etc.) Street opioids (heroin, opium, etc.) Prescription opioids (oxycodone, etc.) In the past year, how often have you used the following: CocaineNeverOnce or TwiceMonthlyWeeklyDaily or Almost DailyRX amphetaminesNeverOnce or TwiceMonthlyWeeklyDaily or Almost DailyStreet opioidsNeverOnce or TwiceMonthlyWeeklyDaily or Almost DailyMethamphetamineNeverOnce or TwiceMonthlyWeeklyDaily or Almost DailyInhalantsNeverOnce or TwiceMonthlyWeeklyDaily or Almost DailySedativesNeverOnce or TwiceMonthlyWeeklyDaily or Almost DailyPrescription opioidsNeverOnce or TwiceMonthlyWeeklyDaily or Almost DailyHallucinogensNeverOnce or TwiceMonthlyWeeklyDaily or Almost DailyAlcohol (For men, 5 or more drinks a day. For women, 4 or more drinks a day)NeverOnce or TwiceMonthlyWeeklyDaily or Almost DailyTobacco productsNeverOnce or TwiceMonthlyWeeklyDaily or Almost DailyDrug of choiceDate of last useHave you tried to quit before? Yes No Longest period of abstinence?How many children do you have? 0 1 2 3 or more How has your chemical use affected the relationship with your children?How has your relationship with family/significant other been affected by your chemical use?Have you ever been physically or sexually abused? Yes Second Choice Does anyone in your immediate family have a problem with chemicals? Yes No Have concerned person(s) complained about your use of chemicals? Yes No What do you normally do with your leisure time?How many close friends do you have?What are your interests/hobbies?Do you socialize with people who use drugs and/or alcohol? Yes No Percent of leisure time spent drinking/using?Is there anything else about either your history or your current condition that you feel is important to mention?
