Behavioral Health Services
Substance Abuse Screening Sheet
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of professional completing this form
*
First Name
Last Name
What is your role?
*
Program Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Name of Client
*
First Name
Last Name
Date of Birth
*
Gender Assigned at Birth
Please Select
Male
Female
Gender Identity
Preferred Pronouns
Social Security Number
*
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Marital Status
Never Married
Seperated
Married
Divorced
Widowed
Do they any children under 18 years old?
Please Select
Yes
No
Highest Grade Level Completed
Source of Monthly Income?
SNAP
TDAP
SSI
SSDI
EMPLOYMENT
Unemployed
Medical Insurance name
*
Medical Insurance ID number
*
Drug History
*
Rows
How Often
Route
Last Used
Age of 1st Use
Withdrawal Symptoms (past & present)
Alcohol
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Benzos
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Cocaine
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Heroin
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Hallucinogens
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Marijuana
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Stimulants
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Oxycodone
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Cigarettes
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Methamphetamine
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Other
Daily
Weekly
IV
ORAL
SMOKE
NASAL
Hospitalized in the last 30 days for suicidal / homicidal thoughts or plans?
Please Select
YES
NO
If Yes, What hospital?
Current suicidal ideation, thought or plan?
YES
NO
current symptoms (check all that apply)
*
Racing thoughts
depressed mood
impulsivity
sleep pattern disturbance
anger
anxiety attacks
poor concentration
hopelessness
homicidal thoughts
ticks, twitching, uncontrollable movement
crying spells
increased irritability
avoidance or isolation
none of these
Any visual or auditory hallucinations?
*
Please Select
YES
NO
How did you hear about our program?
Are they currently taking any Prescribed Medications?
Please Select
YES
NO
If yes, Please list medications:
Are they currently enrolled in a maintenance program such as Methadone or Suboxone?
Please Select
YES
NO
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?
Please Select
YES
NO
Expected discharge date:
Do they need transitional housing?
Please Select
YES
NO
Please list any Medical Health Conditions
Do they have difficulty going up and down stairs?
*
Please Select
YES
NO
Do they use any of the support items below?
*
Cane
Walker
Oxygen
Any other assistive equipment
None
Do they have any open wounds that require medical attention?
*
Please Select
YES
NO
Have they been diagnosed with COPD?
Please Select
YES
NO
Do they need any assistance with paperwork such as reading, writing or reviewing forms?
Please Select
YES
NO
Any open criminal charges?
Please Select
YES
NO
Any arrest in the past 12 months?
Please Select
YES
NO
Are they on Parole or Probation?
Please Select
YES
NO
If so, for what and how long?
Any Gambling Problems?
Please Select
YES
NO
What is the reason for the referral?
*
Additional information you feel is important to include.
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