Substance Abuse Assessment Form Page 3
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5Family problems that are pre-existing, or are exacerbated by substance use:
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Quarrels
Domestic Violence
Family abuses alcohol/ drugs
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Family worried about client’s
Child Abuse
Child Neglect
use
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Separated
Divorce
None
Legal problems:
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DUI
Public intoxication
Other substance-related arrest
None
Other (specify)
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Financial problems:
Some
Moderate
Severe
None
Describe:
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Social problems:
Some
Moderate
Severe
None
Describe:
Mental health disorders that are pre-existing, or have been exacerbated by substance use:
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Increased tolerance
Hangovers
Liver
Stomach
Physical or medical
disease
ailments
problems:
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Experiences
Heart
Blackouts
Other medical
withdrawal
ailments
problems
symptoms
Comment:
Medications currently being prescribed (specify):
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Evidence of psychological dependence to substances?
Yes
No
Comment:
Page 3 of 5
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Parent category: Medical