Substance Use Risk Assessment Form
Please complete this confidential assessment to help us understand your substance use risk and provide appropriate support.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Substance Use Frequency (in the past 12 months)
*
Rows
Never
Once or Twice
Monthly
Weekly
Daily or Almost Daily
Alcohol
1
2
3
4
5
Tobacco/Nicotine
6
7
8
9
10
Cannabis/Marijuana
11
12
13
14
15
Prescription Medications (non-medical use)
16
17
18
19
20
Illicit Drugs (e.g., cocaine, heroin, methamphetamines)
21
22
23
24
25
Have you ever experienced any of the following as a result of substance use? (Select all that apply)
*
Problems at work or school
Legal issues
Relationship or family conflicts
Physical health problems
Mental health concerns (e.g., anxiety, depression)
None of the above
Other (please specify)
How concerned are you about your current substance use?
*
Not at all concerned
1
2
3
4
Extremely concerned
5
1 is Not at all concerned, 5 is Extremely concerned
Have you tried to cut down or stop using substances in the past year?
*
Yes, successfully
Yes, but not successfully
No, I have not tried
Are you interested in receiving help or support for substance use?
*
Yes, I am interested
Maybe/I am unsure
No, I am not interested
Please rate your current stress level
1
2
3
4
5
Do you have a strong support system (family, friends, community)?
Yes
No
Not sure
Additional comments or anything else you would like us to know
Submit Assessment
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