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Alcohol and Drug Evaluation Form Template

Streamline your assessments with our user-friendly form template

Completing thorough evaluations for substance abuse can be challenging, but the right tools can make all the difference. This alcohol and drug evaluation form template is designed for rehabilitation centers and professionals seeking a structured way to assess individuals dealing with addiction. Benefit from comprehensive assessment questions, an easy-to-use format that requires no coding, and the ability to capture essential patient information efficiently. Ensure compliance with professional standards while providing a supportive environment for recovery-explore the live template today.

Use this Template (FREE) Live Preview
I consent to participate in this alcohol and drug evaluation.
Yes
No
If you are not the client, what is your relationship to the client?
Are you completing this form for yourself?
Yes
No
Full name
Date of birth
City and state of residence
Phone number
Email address
Preferred contact method(s)
Phone call
Text message
Email
No preference
What is the primary reason for this evaluation?
Who referred you for this evaluation?
Self
Family or friend
Employer
Court or legal
School
Healthcare provider
Prefer not to say
Other
Please Specify:
Do you currently use alcohol or other drugs?
Yes
No
In the past 30 days, how often did you drink alcohol?
Never
Rarely
Sometimes
Often
Always
Not applicable
In the past 30 days, how often did you use cannabis (marijuana)?
Never
Rarely
Sometimes
Often
Always
Not applicable
In the past 30 days, how often did you use other substances (e.g., cocaine, methamphetamine, heroin, non-prescribed pills)?
Never
Rarely
Sometimes
Often
Always
Not applicable
Have you experienced any of the following related to alcohol or drug use? Select all that apply.
Do you have a safe place to stay tonight?
Yes
No
In the past month, have you had thoughts of harming yourself or others?
Yes
No
Prefer not to say
Current medical conditions (if any)
History of mental health diagnosis or treatment
Yes
No
Not sure
Prefer not to say
Have you ever received treatment for alcohol or drug use?
Yes
No
If yes, which types of services have you used?
Please Specify:
Do you have any current legal issues?
Yes
No
Prefer not to say
I am ready to make changes to my alcohol or drug use.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
What is your primary goal at this time?
No change right now
Reduce use
Stop use
Complete an evaluation only
Learn more about my options
Meet a legal or employer requirement
Prefer not to say
Other
Please Specify:
Which services are you interested in discussing?
Please Specify:
Preferred appointment times
Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
Virtual/phone preferred
In-person preferred
No preference
Type your name as your signature
Date signed
I confirm the information I have provided is accurate to the best of my knowledge.
Yes
No
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Paper art illustration relevant to Alcohol and Drug Evaluation Form Template FormCreatorAI

When to use this form

Use this form at intake for outpatient treatment, DUI or court-ordered screenings, campus conduct reviews, or employee assistance referrals. It helps you capture substance type, frequency, last use, risk factors, and impacts, so you can triage level of care and document a clear plan. Counselors, case managers, and telehealth teams use it to standardize interviews and reduce missed red flags. Pair it with a Psychosocial assessment form to add social, housing, and support context. For a broad mental health baseline you can track over time, include the Mental health survey form. The result is a defensible summary you can share with clients and referral partners.

Must Ask Alcohol and Drug Evaluation Questions

  1. Which substances have you used in the past 12 months, and how often?

    This narrows scope and shows patterns that signal tolerance or binge risk. Specifics improve screening and help you match services and referrals.

  2. On a typical day or week, how much do you use and by what method (oral, inhalation, injection)?

    Dose and route change overdose and withdrawal risk. These details guide safety planning and level-of-care decisions.

  3. When was your most recent use, and have you experienced withdrawal symptoms?

    Recent use and withdrawal history help you plan detox needs and timing. It supports medical referrals and documentation.

  4. How has your use affected work or school, relationships, health, finances, or legal status?

    Functional impact shows severity and where to target change. It also creates objective anchors for goals, progress notes, and outcomes.

  5. Do you have symptoms of depression, anxiety, trauma, or grief, and are you receiving care?

    Co-occurring conditions often drive use or relapse. Use tools like the PHQ-9 & GAD-7 form and the PTSD Checklist - civilian version (PCL-C) form to guide assessment and coordinated care.

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