Addiction Psychiatry Assessment Questionnaire
A structured assessment form to understand substance use patterns, related symptoms, treatment history, and readiness for support.
Assessment Details
Current Age Range
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Other
Primary Reason for Assessment
*
Main Substance(s) of Concern
*
Alcohol
Cannabis
Opioids
Stimulants
Sedatives
Nicotine
Other
Current Frequency of Use
*
Not currently using
Less than monthly
Monthly
Weekly
Several times per week
Daily or almost daily
Multiple times per day
Use Pattern and Severity
Substance Use Severity Details
*
Impact on Work, School, Relationships, or Daily Responsibilities
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Additional details about use pattern or severity
Treatment History and Support
Prior treatment or recovery history
*
None
Outpatient counseling
Inpatient/residential care
Medication-assisted treatment
Mutual support groups
Other
Current support system strength
*
Very weak
1
2
3
4
5
6
7
8
9
Very strong
10
1 is Very weak, 10 is Very strong
Readiness to change or treatment goals
*
Not ready to change
Thinking about change
Preparing to change
Actively working on recovery
Maintaining recovery
Other
Submit
Should be Empty: