Chemical Dependency Evaluation Interview Form Page 2
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7Type of job? Is there travel involved?
EAP contact at employer:
Previous employment history/reasons for leaving job:
Have you ever been disciplined for absences or tardiness in any job (please explain):
Has drinking or drug use ever affected your job?
Spouse’s employer:
E. Educational/Military Status - History
Highest level of education:
Have you served in the military?
What branch?
Years served:
Type of discharge:
Difficulties in service…(include arrests etc.)
F.
Drug/Alcohol Use
(Alcohol or Drug Type)
Ages
Frequency
Amounts
Methods of Use
Comments
Consequences
Last Use:
Amount:
Method of use:
(Alcohol or Drug Type)
Ages
Frequency
Amounts
Methods of Use
Comments
Consequences
Last Use:
Amount:
Method of use:
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