Behavioral Health Services SUD Screening Form

Date

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Date of Birth

Gender Assigned at Birth

Gender Identity

Preferred Pronouns

Social Security Number

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Marital Status

Do you have any children under 18 years old?

Highest Grade Level Completed

GED

Source of Monthly Income?

Amount of Income

Medical Insurance name

Medical Insurance ID number

Drug History

Rows	How Often	Route	Last Used	Age of 1st Use	Withdrawal Symptoms (past & present)
Alcohol
Benzos
Cocaine
Heroin
Hallucinogens
Marijuana
Stimulants
Oxycodone
Cigarettes
Methamphetamine
Other

Have you been hospitalized in the last 30 days for suicidal / homicidal thoughts or plans?

If Yes, What hospital?

Do you currently feel like you dont want to live?

What are your current symptoms (check all that apply)

Have you been admitted to a psychiatric facility within your lifetime?

If Yes, what facility and when were you admitted?

Do you ever have hallucinations?

Do you ever hear voices?

What Programs are you interested in enrolling in?

How did you hear about our program?

Do you have a Mental Health Provider

If yes, Provider's Name

Do have any Psychological/ emotional Problems?

If yes, what is your diagnosis?

Do you have a Primary Care Provider?

if yes, Name of Provider and Date of Last Visit?

Are you taking any Prescribed Medications?

If yes, Please list medications:

Are you currently enrolled in a maintenance program such as Methadone or Suboxone?

If Yes, Please list Name and Location of facility

Please list all Prior treatment history program name and dates:

Are you transferring from an IOP or Inpatient program?

If so, Name or Program

Expected discharge date:

Have you been enrolled in an outpatient substance abuse program in the last year?

Why did you leave you previous treatment program?

Do you need transitional housing?

Are you homeless?

If no, Are there any alcohol or drugs in your current home?

Who do you reside with?

When was the last you drank alcohol?

When was the last time you ingested heroin/fentanyl?

How many times have you overdosed?

Do you take non-prescribed medication such as Oxycontin, Xanax, Ambien, Gabapentin?

Please list any Medical Health Conditions you have and any medications you take for those conditions, for example medications for high blood pressure, seizures, etc

Do you have difficulty going up and down stairs?

Do you use any of the support items below?

Do you have any open wounds that require medical attention?

Have you been diagnosed with COPD?

Do you need any assistance with paperwork such as reading, writing or reviewing forms?

Do you have any open criminal charges?

Have you been arrested in the past 12 months?

Are you on Parole or Probation?

Has a Court or Judge required you to attend treatment?

If so, for what and how long?

Do you have any Gambling Problems?

In your own words, What is your present problems; your priority as it pertain to your treatment.

Additional information you feel is important to include.