Substance Abuse Assessment Form Page 2
ADVERTISEMENT
1
2
3
4
5□
□
Has client been intoxicated, hungover, or in withdrawal at times when he/she is
Yes
No
expected to fulfill important obligations, such as while at work?
If Yes, describe:
□
□
Has client given up occupational, social or recreational activities because of substance use?
Yes
No
If Yes, describe:
Has client used drugs and/or alcohol to ease difficulties with emotions, relationships, or as a stress reliever?
□
□
Yes
No
If Yes, describe:
□
Violation of the Employer’s substance abuse policy, example: a positive drug test.
Work problems:
□
□
□
Absenteeism
Tardiness
Accidents
□
□
Working while hung-over
Trouble concentrating
□
□
Decreased job performance
Consumed substances while at work
□
□
Lost job in past due to substance abuse
No work problems
Comments:
□
□
□
Client’s perception of substance use:
Not a problem
Unsure if problem
Some problem
□
□
□
Significant
Severe problem
Actively wants help
problem
Page 2 of 5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ma-7 - Petition And Affidavit Seeking Involuntary Substance Abuse Assessment And Stabilization
Legal
Form Dss-8224 - Work First Program Referral To Qualified Professional In Substance Abuse - North Carolina
Legal
Form Prob 11e - Authorization To Release Confidential Information Substance Abuse And Mental Health Treatment Programs - U.s. Probation System
Legal
Related Categories
Parent category: Medical