Chemical Dependency Evaluation Interview Form Page 3
ADVERTISEMENT
1
2
3
4
5
6
7(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:
When was your heaviest drinking/drug use?
What was going on in your life at that time?
Describe times when you have cut back or stopped drinking/using drugs:
For how long:
What helped?
What triggered the relapse:
Do you think you can quit now?
Why or why not?
Drug & Alcohol Symptom Assessment
Has it ever occurred that you drank or used more than you intended? Describe…when was most
recent occurrence?
3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business