Substance Use Rehabilitation Assessment
Please complete this assessment to help us understand your needs and support your recovery journey.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which substances are you seeking help for?
*
Alcohol
Cannabis
Opioids (e.g., heroin, prescription painkillers)
Stimulants (e.g., cocaine, methamphetamine)
Sedatives or tranquilizers
Other
How often have you used these substances in the past 30 days?
*
Rows
Never
1-2 times
Weekly
Daily
Alcohol
1
2
3
4
Cannabis
5
6
7
8
Opioids
9
10
11
12
Stimulants
13
14
15
16
Sedatives/Tranquilizers
17
18
19
20
Other
21
22
23
24
How has substance use affected the following areas of your life?
*
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Physical Health
25
26
27
28
Mental Health
29
30
31
32
Relationships
33
34
35
36
Employment/Education
37
38
39
40
Legal Issues
41
42
43
44
Have you previously received treatment for substance use?
*
Yes
No
If yes, please describe previous treatments (type, duration, outcome):
How motivated are you to make changes regarding your substance use?
*
Not motivated
1
2
3
4
5
6
7
8
9
Highly motivated
10
1 is Not motivated, 10 is Highly motivated
Do you have any mental health concerns or diagnoses?
*
Yes
No
If yes, please specify:
Who are your main sources of support?
Family
Friends
Support Group
Healthcare Provider
Other
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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