Legal Full Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Please share with me the circumstances of your referral (the reason you need to complete the chemical use evaluation) in your own words.
*
Relationship Status:
*
Married
Engaged
Separates
Single
Dating
Other
How do you identify with regards to ethnicity? (Examples: Caucasian, Hispanic, Asian, etc)
*
Do you have any children?
*
Yes
No
How many and what are their ages?
Are you currently employed?
*
Yes
No
Where do you work?
What position do you fill?
How long have you been with your employer?
Where did you grow up?
*
Did you grow up in an intact home with mom & dad or another primary care giver?
*
Intact Home with Mom & Dad
Other Primary Care Giver
None
Other
Do you have brothers and sisters?
*
Yes
No
How many?
Did you graduate from High School?
*
Yes
No
What year did you graduate from high school?
What was the name of your high school?
*
Were you actively involved in sports or other organized activities?
*
Yes
No
List the sports and activities:
What kind of grades did you get while in school?
*
Did you attend college at any point?
*
Yes
No
What college did you attend?
What degree were you pursuing?
Did you obtain a degree?
Yes
No
What year did you complete the program?
Have you served in the military?
*
Yes
No
In what branch of the military did you serve?
How many years did you serve?
What type of discharge did you receive?
What was your rank at the time of discharge?
Besides the situation that brought you to this assessment do you have any other charges or convictions on your record?
*
Yes
No
Please explain:
Have you ever participated in alcohol or drug education?
*
Yes
No
Have you ever participated in alcohol or drug treatment programming?
*
Yes
No
Do you have any ongoing, persistent or debilitating medical conditions that affect your day to day function?
*
Yes
No
Please explain:
Please answer yes or no to the following questions based on whether you have experienced any of these things within the past 12 months leading up to the day of our meeting?
*
Rows
Yes
No
Have you ever switched to different drinks or drugs or changed your using pattern in an effort to control or reduce your consumption?
Have you ever sneaked or hidden your use?
On occasion, do you feel uncomfortable if alcohol or your drug is not available?
Have you ever felt guilty or ashamed about your drinking or using or what you did while under the influence?
Has your efficiency decreased as a result of your drinking or using?
When using or drinking, do you neglect to eat properly?
Do you use or drink alone?
Do you use or drink more than usual when under pressure, angry, or depressed?
Are you able to drink or use more now without feeling it, compared to when you first started using?
Have you ever gotten into financial, legal, or marital difficulties due to using?
Have you lost interest in other activities or noticed a decrease in your ambition as a result of your drinking or using?
Have you had the shakes or tremors following heavy drinking or using or not using for a period of time?
Do you want to drink or use at a particular time each day?
Do you go on and off the wagon?
Submit
Should be Empty: