Fillable Printable Substance Abuse Assessment Form
Fillable Printable Substance Abuse Assessment Form
Substance Abuse Assessment Form
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SUBSTANCE ABUSE ASSESSMENT FORM
Please make copies as needed and please type or print legibly.
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:
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.
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Has client been intoxicated, hungover, or in withdrawal at times when he/she is
expected to fulfill important obligations, such as while at work?
□ Yes
□ No
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:
Work problems: □
Violation of the Employer’s substance abuse policy, example: a positive drug test.
□
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
problem
□
Severe problem
□
Actively wants help
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Family problems that are pre-existing, or are exacerbated by substance use:
□
Quarrels
□
Domestic Violence
□
Family abuses alcohol/ drugs
□
Child Abuse
□
Child Neglect
□
Family worried about client’s
use
□
Separated
□
Divorce
□
None
Legal problems:
□
DUI
□
Public intoxication
□
Other substance-related arrest
□
None
Other (specify)
Financial problems:
□ Some □ Moderate □ Severe □ None
Describe:
Social problems:
□ Some □ Moderate □ Severe □ None
Describe:
Mental health disorders that are pre-existing, or have been exacerbated by substance use:
Physical or medical
problems:
□
Increased tolerance
□
Hangovers
□
Liver
disease
□
Stomach
ailments
□
Experiences
withdrawal
symptoms
□
Heart
ailments
□
Blackouts
□
Other medical
problems
Comment:
Medications currently being prescribed (specify):
Evidence of psychological dependence to substances?
□ Yes □
No
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Comment:
Has the client attempted to cut down or stop alcohol and drug use:
□
Yes
□
No
(Describe)
Control over use:
□
No loss of control
□
Uses more than intends
□
Getting worse
□
Unpredictable
□
Uses to get high
□
Gets argumentative
□
Increased tolerance
History of suicide attempts (describe):
History of violent behavior (describe):
Previous treatment:
□ None □ Yes
(Describe: date, type, setting, and outcome)
Reports from collateral contacts (spouses, family, friends) concerning the client's substance use:
Additional Assessment Comments:
Multi-Axial DSM IV Diagnostic Impressions
Axis I:
Axis II:
Axis III:
Axis IV:
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Axis V:
Prognosis:
□
Excellent
□
Good
□
Fair
□
Poor
Your 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:
EAP CONSULTANTS, LLC
One Parkway Center
1850 Parkway Place, Suite 700
Marietta, GA 30067
678-384-3839 (Fax)
800-522-1073 (Telephone)
