INTAKE: Self Alcohol/Drug Assessment

Name*

Date*

Date

Please answer all the following questions. All the information is kept in strict confidence and may not be disclosed without your permission.

1. At what age were you when you first took one or more drinks or used drugs?*

2. How old were you when you first became intoxicated or high?*

3. How many years have you been drinking or using?*

4. How often do you drink or use?*

DailyWeeklyMonthlyOther

5. What is the most positive or desirable effect of alcohol or drugs for you?*

6. When was your last drink, or use?*

How much?*

7. What particular situations or feelings would likely make you drink or use?*

8. Have you had periods of not remembering events, during, or after the time you were drinking?*

9. Have you had any medical problems directly related to drinking or using?*

10. How is your general health?*

11. Do you feel that you have a drinking or drug problem impacting your life now?*

12. In what ways has your drinking or using caused you problems?*

13. Do you consider your drinking or using to be alcoholic/addictive?*

14. What was your Blood Alcohol Content at the time of your arrest?*

Do you feel you were in control?*

15. Are you currently taking prescription medication?*

lf so, what?

16. Have you used street drugs in the past? (cocaine, methamphetamine, pot, etc)*

lf so, what?

17. Are you currently using drugs?*

lf so, what?

18. Have you attended counseling (marriage, family, Individual, alcohol/drug treatment)?*

If so, when?

19. Have you considered or been suggested to attend AA/NA?*

If so, are you attending?

20. Is anyone in your family alcoholic or drug dependent?*

lf so, who?

21. Legal History? (Current)*

(Past)*

22. Current Age?*

23. Are you employed?*

Client's Name*

Signature*

Date*

Date

SIMPLE ASSESSMENT TOOL FOR AOD ABUSE