Do you currently use alcohol?
Yes   No   
If yes, how often do you drink? Daily, weekly, occasionally, or rarely:
Daily   Weekly   Occasionally   Rarely         
If yes, how much do you drink? (#) Per time:
 
Do you currently use Tobacco?
Yes   No   
If yes, how much do you smoke/chew?
   
Do you currently use any other drugs?
Yes   No   
If yes, what drugs do you use?
   
If yes, how often do you use?
Daily   Weekly   Occasionally   Rarely   
Have you received any previous treatment for chemical use?
   
If so, where did you go?
   
Inpatient or Outpatient?
Inpatient    Outpatient   
Have you ever used more than 1 chemical at the same time to get high?
   
Do you avoid family activities so you can use?
   
Do you have a group of friends who also use?
   
Do you use to improve your emotions such as when you feel sad or depressed?
   

Please describe your home environment and current relationships within the household. Who do you currently live with?
Spouse:
Type a label   
Children (age):
Type a label   
Other members of the household (age):
Type a label   

Are you working now?
Yes   No   
Full-time or Part-Time?
Please Select Full-Time Part-Time