Substance Abuse Assessment Form Page 5
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5Your recommendations for this client’s treatment: (please check all that apply)
□
Intensive outpatient substance abuse treatment program
Duration
□
Inpatient substance abuse treatment or detoxification
Duration
□
Self-help or 12 Step Groups
Frequency
Duration
□
Random Drug Testing
Frequency
Duration
□
Other outpatient treatment
Frequency
Duration
Additional comments about treatment recommendations, or if you conclude that no further EAP or treatment services are
needed or recommended, please comment:
Please specify the program, facility or counselor you are recommending to provide above services:
Name:
Location:
Telephone # if known:
Date the client agrees to begin treatment: __________________________________________________
Additional comments:
Counselor Signature
Date
Thank you.
PLEASE SUBMIT TO:
ESPYR
One Parkway Center
1850 Parkway Place, Suite 700
Marietta, GA 30067
678-384-3839 (Fax)
800-522-1073 (Telephone)
Page 5 of 5
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