Substance Use Declaration Form
Please fill out this form truthfully regarding your substance use.
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Have you used any recreational drugs in the past 12 months?
Yes
No
If yes, please specify the substances used
Do you consume alcohol?
Yes
No
If yes, please specify frequency and quantity
Are you currently undergoing any treatment for substance use?
Yes
No
If yes, please provide details
Submit
Should be Empty: