Substance Abuse Assessment Form
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5SUBSTANCE ABUSE ASSESSMENT FORM
Please make copies as needed and please type or print legibly.
Instructions for use: Complete this form and use these questions to guide the EAP client interview when
conducting a formal substance abuse assessment to determine a client’s treatment needs. Thank you.
Client’s Name:
Client’s Job Title or Position:
Client’s Employer:
Counselor’s Name:
Reason for the Client’s Referral (include details that lead to a formal EAP referral by the employer if applicable):
Substances used and history:
Alcohol:
____ Never used ____Currently using ____ Past use ____Age first used
Amphetamines
____ Never used ____Currently using ____ Past use ____Age first used
Anti-anxiety (e.g. Valium)
____ Never used ____Currently using ____ Past use ____Age first used
Barbiturates
____ Never used ____Currently using ____ Past use ____Age first used
Cocaine/crack:
____ Never used ____Currently using ____ Past use ____Age first used
Heroin/morphine:
____ Never used ____Currently using ____ Past use ____Age first used
LSD/acid
____ Never used ____Currently using ____ Past use ____Age first used
Marijuana/hash:
____ Never used ____Currently using ____ Past use ____Age first used
Meth/Crystal meth:
____ Never used ____Currently using ____ Past use ____Age first used
Painkillers (e.g., Oxycontin)
____ Never used ____Currently using ____ Past use ____Age first used
Other (specify)
____ Never used ____Currently using ____ Past use ____Age first used
Describe type, amount and frequency of use for each substance indicated above:
□
□
Has client used drugs and/or alcohol in situations where it is physically
dangerous, such as driving while impaired?
Yes
No
If Yes, describe:
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