Drug & Alcohol Counseling Intake Forms & Client Questionnaires

The client sitting across from you at an initial substance use assessment is not there because things are going well. They may be court-ordered after a second DUI, referred by an EAP after a workplace incident, coming in voluntarily after a family intervention, or transferring from an inpatient detox program that discharged them three days ago. Each of these scenarios demands different information at intake — legal mandates and reporting obligations, employment status and drug testing requirements, withdrawal risk factors, and continuity of care from a prior treatment episode. A generic mental health intake form does not ask about substance of choice, route of administration, age of first use, longest period of sobriety, or number of prior treatment admissions. The Drug & Alcohol Counseling intake form does.

The form opens with a comprehensive substance use inventory organized by category: alcohol, cannabis, opioids (heroin, fentanyl, prescription painkillers), stimulants (cocaine, methamphetamine, prescription amphetamines), benzodiazepines, barbiturates, hallucinogens, inhalants, synthetic cannabinoids, and nicotine/tobacco. For each substance, it captures age of first use, current frequency and quantity, route of administration (oral, intranasal, intravenous, smoked, sublingual), date of last use, and whether the client considers it a current problem. This level of detail matters clinically. A client who reports drinking “socially” may mean four beers on a Saturday or a fifth of vodka every night — the form forces specificity that a free-text field never will.

Treatment History and Prior Episodes

Substance use disorder is a chronic relapsing condition, and most clients presenting for treatment have been through some form of treatment before. The form captures each prior treatment episode: facility name, dates, level of care (ASAM levels — outpatient, intensive outpatient, partial hospitalization, residential, medically managed detox), primary substance treated, whether the client completed the program or left against medical advice, and the length of sobriety achieved after discharge. This treatment history is not academic. A client with three prior residential episodes who relapsed within weeks of each discharge needs a fundamentally different treatment plan than a first-time outpatient referral. The pattern of prior treatment failures tells you what has not worked and helps you avoid repeating it.

The form also captures current and prior medication-assisted treatment (MAT). For opioid use disorder, it records whether the client is currently on or has previously taken methadone, buprenorphine (Suboxone, Subutex, Sublocade), or naltrexone (Vivitrol). For alcohol use disorder, it captures disulfiram (Antabuse), naltrexone, and acamprosate history. It records prescribing provider, current dose, adherence issues, and whether the client has ever diverted or misused their MAT medication. This information is essential for coordination with the prescribing physician and for developing a treatment plan that integrates pharmacological and psychosocial interventions.

Legal Status and Court-Ordered Treatment

A significant percentage of substance abuse treatment admissions involve some form of legal mandate. The form captures whether the client is court-ordered to treatment, on probation or parole, involved in drug court, facing pending charges, or subject to child protective services involvement. It records the name and contact information of the probation or parole officer, the specific conditions of the court order (treatment completion, random drug testing, attendance verification), reporting requirements, and consequences of non-compliance. For drug court participants, it captures the phase of the program, scheduled court review dates, and any sanctions or incentives already imposed.

This legal overlay changes the clinical dynamic. A court-ordered client may be in pre-contemplation — not yet acknowledging a problem — and attending only to satisfy a legal obligation. Your treatment approach must account for this motivational stage. The form also captures whether the client has any pending DUI/DWI charges, a history of drug-related offenses, or any active warrants, because these factors affect scheduling, transportation, and the risk of treatment interruption due to incarceration. The companion mental health intake form covers the broader psychiatric assessment; this form focuses on the substance-specific clinical and legal dimensions.

Co-Occurring Disorders and Family Dynamics

Dual diagnosis is the rule, not the exception, in substance abuse treatment. The form includes a co-occurring disorders screening that captures current and past mental health diagnoses (depression, anxiety, PTSD, bipolar disorder, schizophrenia, ADHD, personality disorders), current psychiatric medications, history of psychiatric hospitalization, and history of suicidal ideation, attempts, or self-harm. It also screens for trauma history — physical abuse, sexual abuse, emotional abuse, neglect, domestic violence, combat exposure — because unaddressed trauma is one of the most common drivers of relapse.

Family and social history is equally critical. The form captures family substance use history (parents, siblings, spouse/partner, children), current living situation (stable housing, shelter, homeless, sober living, incarcerated family member), primary relationships and their substance use status, dependent children and custody arrangements, and current support system. It asks whether the client’s partner or household members currently use substances, because a client returning from residential treatment to a home where their partner is actively using faces relapse risk that no amount of coping skills training can fully mitigate. The intake must capture these environmental factors so your treatment plan can address them — whether through family therapy referrals, sober living placement, or safety planning.

Pricing

The complete drug & alcohol counseling set is $19.99 (intake form + client questionnaire), $14.99 for intake only, or $9.99 for questionnaire only. All PDFs are fillable in Adobe Reader, password-protected against editing, and HIPAA-compliant.

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