Hiawatha Valley Substance Abuse History Form

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SUBSTANCE ABUSE HISTORY FORM
Thank you for taking the time to completely fill out this form as it will help us to better understand you and your
situation. The information you provide here is confidential and will only be shared with your clinician.
IDENTIFYING INFORMATION
Last
First
Middle
Name
Former Name(s)
Street
Address
City
State
Zip
Home:
Cell:
Work:
Telephone
Today's Date
DOB
Age
General
Number of years of education
Social Security #:
Present Occupation
Employer Name:
Occupation:
Hispanic or Latino
Non-Hispanic or Latino
Decline
Ethnicity
American Indian
Alaska Native
Asian
White
Native Hawaiian
Other Pacific Islander
African American
Decline
Race
English
Spanish
Hmong
Mandarin
Other _________________________
Language
HEALTHCARE PROVIDER INFORMATION
Name
Phone
Do you have a regular physician?
Yes
Address _____________________________________
No
Do you want a summary sent to this person (as listed above)?
Yes
No
Has a health care provider/healer ever recommended that you reduce or quit alcohol/drug use?
Yes
No
Were you referred here by someone?
Yes
Who sent you? _________________________________________________
Address: _________________________________________________
No
Do you want a summary sent to this person?
Yes
No
What are the major
concerns or issues
that bring you to
our Center?
List any previous
mental health
therapy you have
had.
___________________________________________________
_______________________________________
Signature of Person Completing Form and Relationship to Client
Date
1

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