Substance Usage Addendum
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Alcohol- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Alcohol- Last Use
*
Within the Last Week
Within Past Month
Over 1 Month Ago
Never
Marijuana/Hash- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Marijuana/Hash- Last Use
*
Within the Last Week
Within Past Month
Over 1 Month Ago
Never
Cocaine (Powder, Crack)- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Cocaine (Powder, Crack)- Last Use
*
Within the Last Week
Within Past Month
Over 1 Month Ago
Never
Amphetamines (Crystal Meth)- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/ Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Amphetamines (Crystal Meth)- Last Use
*
Within the Last Week
Within Past Month
Over 1 Month Ago
Never
Sedatives- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Sedatives- Last Use
*
Within the Last Week
Within Past Month
Over 1 Month Ago
Never
Minor Tranquilizers (Valium)- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Minor Tranquilizers (Valium)- Last Use
*
Within the Last Week
Within the Past Month
Over 1 Month Ago
Never
Hallucinogens- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Hallucinogens- Last Use
*
Within the Last Week
Within the Past Month
Once a Month or Less
N/A
Barbiturates- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Barbiturates- Last Use
*
Within the Last Week
Within the Past Month
Once a Month or Less
N/A
Heroin- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Heroin- Last Use
*
Within the Last Week
Within the Past Month
Once a Month or Less
N/A
Other Opiates/Narcotics- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Other Opiates/Narcotics- Last Use
*
Within the Last Week
Within the Past Month
Once a Month or Less
N/A
Inhalants- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Inhalants- Last Use
*
Within the Last Week
Within the Past Month
Once a Month or Less
N/A
Other (Please List Below or put "N/A)- Typical Frequency of Use in the Last 6 Months
*
Daily
1-6 Times/Week
Weekend Use Only
Few Times a Month
Once a Month or Less
N/A
Other (Please List Below or put "N/A)- Last Use
*
Within the Last Week
Within the Past Month
Once a Month or Less
N/A
Have you ever been involved in a 12 step/AA program?
*
Yes, Currently
Yes, But Not Currently
No
Have you ever received outpatient AODA (Alcohol and Other Drug Abuse) treatment?
*
Yes, Currently
Yes, But Not Currently
No
Have you ever received inpatient AODA (Alcohol and Other Drug Abuse) treatment?
*
Yes, Currently
Yes, But Not Currently
No
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