Virtual Substance Use Evaluation Intake Form
Complete this intake form to request a virtual substance use evaluation and share the basic information needed to schedule the session.
Intake Details
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Virtual Appointment Date/Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Primary Reason for Evaluation
*
Substance Use History
Substances Used
*
Alcohol
Cannabis
Opioids
Stimulants
Sedatives
Nicotine
Other
Frequency of Use
*
Daily
Weekly
Monthly
Less than monthly
Not currently using
Time of Most Recent Use
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Support and Safety
Current support needs or concerns
Emergency contact name
*
Emergency contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Acknowledgement
*
I understand this form is only for intake and scheduling and does not provide medical evaluation or emergency support.
Submit
Should be Empty: