Chemical Dependency Assessment Questionnaire Form
Please complete this assessment questionnaire to help summarize substance use patterns, related impacts, and support needs.
Assessment Details
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Respondent Name or Identifier
Age Range
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
Current Relationship to the Person Being Assessed
*
Self
Family Member
Friend
Clinician
Other
Substance Use Screening
Substances Used
*
Alcohol
Cannabis
Opioids
Stimulants
Sedatives
Nicotine
Other
Frequency of Use
*
Daily
Several times per week
Weekly
Monthly
Less than monthly
Not currently using
Approximate Duration of Use
*
Please Select
Less than 1 month
1–6 months
6–12 months
1–3 years
3–5 years
More than 5 years
Most Recent Use
*
Please Select
Today
Within the past 24 hours
Within the past week
Within the past month
More than 1 month ago
Not applicable
Impact and Risk Assessment
Impact on daily functioning
*
Rows
No impact
Mild
Moderate
Severe
Daily life
1
2
3
4
Work/school functioning
5
6
7
8
Relationships
9
10
11
12
Sleep
13
14
15
16
Mood
17
18
19
20
Physical well-being
21
22
23
24
Have you experienced any of the following?
*
Cravings
Loss of control
Withdrawal symptoms
Unsuccessful attempts to cut down
Not sure
None of the above
Overall impact on your health and well-being
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
How concerned are you about the risks related to substance use?
*
1
2
3
4
5
Support and Readiness
Prior treatment or support history
*
None
Counseling
Support group
Inpatient treatment
Outpatient treatment
Other
Current support system strength
*
Very weak
1
2
3
4
Very strong
5
1 is Very weak, 5 is Very strong
Readiness to change or seek help
*
Not ready
1
2
3
4
Very ready
5
1 is Not ready, 5 is Very ready
Submit Assessment
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