Substance Abuse Psychiatric Assessment Form
Substance Abuse Psychiatric Assessment Form
Initials or Preferred Name
*
Age Range
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55+
Primary Substance of Concern
*
Please Select
Alcohol
Cannabis
Opioids
Stimulants
Sedatives
Hallucinogens
Other
Frequency of Use
*
Please Select
Daily
Several times a week
Weekly
Monthly
Occasionally
Rarely
Duration of Use
Please Select
Less than 6 months
6 months to 1 year
1-3 years
3-5 years
More than 5 years
In the past 30 days, how often have you experienced cravings for the substance?
*
Never
1
2
3
4
Very Often
5
1 is Never, 5 is Very Often
Level of distress or impairment caused by substance use
*
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Have you received treatment or counseling for substance use before?
Yes
No
Please rate your current mood
1
2
3
4
5
Additional Comments or Observations
Submit Assessment
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