Telehealth Psychiatric Substance Use Assessment Form
Please complete this confidential intake assessment to help us understand your current mental health and substance use needs for telehealth services.
Your full name
*
First Name
Last Name
Age
*
Main reason for seeking telehealth assessment
*
Mood concerns (depression, anxiety, etc.)
Substance use concerns
Both mood and substance use concerns
Other mental health concerns
How would you rate your current level of distress?
*
1
2
3
4
5
In the past month, how often have you used any of the following substances?
*
Rows
Never
Monthly or less
2-4 times/month
2-3 times/week
4+ times/week
Alcohol
1
2
3
4
5
Cannabis
6
7
8
9
10
Prescription medications (not as prescribed)
11
12
13
14
15
Illicit drugs
16
17
18
19
20
Tobacco/nicotine
21
22
23
24
25
Have you ever received mental health or substance use treatment before?
*
Yes, mental health treatment
Yes, substance use treatment
Yes, both
No
Are you currently experiencing any of the following? (Select all that apply)
*
Sleep issues
Appetite changes
Difficulty concentrating
Increased irritability
Cravings for substances
Withdrawal symptoms
None of the above
How ready are you to make changes related to your mental health or substance use?
*
Not ready
1
2
3
4
5
6
7
8
9
Very ready
10
1 is Not ready, 10 is Very ready
What is your preferred method of telehealth communication?
*
Video call
Phone call
Text/chat
No preference
Submit Assessment
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