Chemical Dependency Evaluation Interview Form

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CHEMICAL DEPENDENCY EVALUATION INTERVIEW
A. Demographics
DATE OF EVALUATION
COMPANY NAME:
NAME
ADDRESS
PHONE:
MARITAL STATUS
SOCIAL SECURITY #
DATE OF BIRTH
AGE
GENDER
RACE/ETHNICITY
VALID DRIVER’S LICENSE:
YES:
NO:
B. What brought the client in at this time?
C. Medical Status - History
Chronic Medical Problems:
Current Medical Problems:
Hospitalizations includes serious injury or surgery: If so for what, how long, dosage and side
effects.
Outpatient Services:
D. Employment/Support/Work Status and History
Current employer/job:
Employers address:
Years at position:
Income:
1

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