Substance Abuse Diagnostic Evaluation Consent Form

Substance Abuse Diagnostic Evaluation Consent Form
Please complete this form to provide your consent and background information for a substance abuse diagnostic evaluation.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name and Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Provider (if applicable)
Reason for Evaluation / Presenting Concerns

Substance Use Assessment: Please indicate your frequency of use for the following substances in the past 12 months.

Rows	Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
Alcohol
Cannabis/Marijuana
Prescription Drugs (not as prescribed)
Cocaine/Amphetamines
Opioids/Heroin
Hallucinogens
Other (please specify)

Have you previously received treatment for substance use?
If yes, please briefly describe prior treatment (type, dates, outcome):
Do you have any current mental health concerns?
If yes, please describe:
Signature (Please sign below to confirm your consent)
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