Substance Use Evaluation Intake Form Name * First Name Last Name Email * Date of Birth: * MM DD YYYY Gender: * Past Medical History * Past mental health history Does your family have a history of mental health problems? Yes No Have you ever seen a psychiatric provider? like a Psych NP, psychologist or psychiatrist Yes No Current Medical Conditions * Current Medications (including prescribed, over-the-counter, and supplements) * Allergies * Family History of Substance Use Disorders * Substance Use History Which of the following substances have you used? (Please check all that apply and provide details) Alcohol Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: Marijuana Duration of Use: Frequency of Use (daily, weekly, monthly) Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: Cocaine Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: Heroin Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: Methamphetamine Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: Prescription Painkillers (e.g., Oxycodone, Hydrocodone) Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: Prescription Sedatives (e.g., Valium, Xanax) Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: Prescription Stimulants (e.g., Adderall, Ritalin) Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: Ecstasy/MDMA Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: LSD Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: Inhalants (e.g., glue, paint thinners) Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: Other (Please specify): ________________ Frequency of Use (daily, weekly, monthly) Duration of Use: Route of Administration (oral, inhalation, injection, etc.): Quantity Typically Consumed: Any Previous Attempts to Cut Down or Quit? If Yes, Describe: Experience of Withdrawal Symptoms: How has your substance use impacted your daily life? * (work, relationships, legal issues, etc.) On a scale of 1 to 10, how would you rate the severity of your substance use problem? * 1: Not severe at all 10: Extremely severe Do you experience cravings for the substance(s)? * If yes, describe: Have you ever experienced blackouts or memory loss due to substance use? * Yes No Have you ever engaged in risky behaviors while under the influence? * Yes No Have you ever had legal issues related to substance use? * Yes No Additional Information: I consent to this substance use evaluation. I understand that my information will be kept confidential and used for the purpose of this evaluation and treatment planning. * Date * MM DD YYYY Thank you for taking the time to complete the Substance Use Evaluation Intake Form. We appreciate your cooperation and effort in providing the necessary information.Your responses are invaluable in helping us understand your history and current situation to provide you with the best possible care. Please be assured that your information will be kept confidential and used solely for the purpose of this evaluation and treatment planning.We will now review your responses and forward the results to the appropriate individuals as required. If we need any further information or clarification, we will reach out to you promptly.