Substance Abuse Assessment Form Page 4
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Has the client attempted to cut down or stop alcohol and drug use:
Yes
No
(Describe)
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No loss of control
Uses more than intends
Getting worse
Control over use:
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Unpredictable
Uses to get high
Gets argumentative
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Increased tolerance
History of suicide attempts (describe):
History of violent behavior (describe):
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None □ Yes
Previous treatment:
(Describe: date, type, setting, and outcome)
Reports from collateral contacts (spouses, family, friends) concerning the client's substance use:
Additional Assessment Comments:
ICD 10#
Description
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Excellent
Good
Fair
Poor
Prognosis:
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Parent category: Medical