Please fill out every field. If a field does not apply, please fill in with N/A.
Name of applicant for treatment
Name of person completing form
How long do you think the applicant has had a problem with substance use?
What substances does the applicant use (i.e. alcohol, prescription medication, cocaine, etc.)?
When, if ever, was the first time you commented on substance use?
Are you aware of the applicant using substances in secret or when alone?
What are the usual rationalizations/reasons given by the applicant for his/her substance use?
What personality/behaviour changes does the applicant experience when engaged in substance use?
When has the applicant attempted to limit/control substance use?
When has the applicant been totally abstinent from substance use?
Why was the decision to be abstinent made?
How long did this last?
Why did the applicant begin using substances again?
Are you aware of the applicant’s patterns of substance use? (when, where, high risk environments)
On what occasions has the applicant’s substance use caused you embarrassment?
In what ways has the applicant become less interested in family, employment, recreation, or hobbies?
Has the applicant engaged in binge use (using a substance for several days straight)? If so, when was this?
Are you aware if the applicant was ever advised by a doctor that substance use was harming his/her health?
What legal difficulties if any has the applicant experienced as a result of substance use?
Has the applicant ever been threatened with the loss of his/her job as a result of substance use?
How much time and money do you believe the applicant has spent on substance use?
Please give details of previous treatment that the applicant has participated in for substance use
Please describe how your family, including your children, has been affected by the substance use
Have you, or any members of your family, sought out support for yourselves because of the effects of the substance use?
Is there anything else that you feel we need to be aware of?