Chemical Dependency Evaluation Interview Form (Page 4 of 7) in pdf

Chemical Dependency Evaluation Interview Form Page 4

Have you ever had problems in any relationship due to drinking or drug use? (Consider

disagreements, dishonesty, expression of concerns by others):

Have you ever drank or used drugs in a way that kept someone else from knowing about it:

How does drinking or drug use change your mood:

Have you ever regretted your actions towards others (including children) while under the

influence of a chemical substance?

Have you ever noticed that you were able to drink/use more without feeling more intoxicated

than usual? Describe:

How often do you visit bars/taverns/clubs:

Have you drank or used drugs alone? If yes, describe:

Have you ever driven while under the influence of drugs/alcohol: (Please specify which)

Have you ever been injured or had an accident while drinking/using drugs: (Please specify)

How often do you visit casinos or otherwise gamble:

Do your friends drink/use drugs: (Please specify)

Have they ever been arrested or convicted for drug/alcohol use:

Have you ever been in a fight while under the influence of alcohol or drugs?

Have you ever been involved in a situation in which the police were called for peace disturbance:

If so, when?

How often?

Chemical Dependency Evaluation Interview Form Page 4