Substance Abuse Intake Form

Patient Name *

First

Last

Email *

Date of Birth *

Guardian Name *

First

Last

Motivation for Impact

How did you come to SAIOP *

Primary Reason for Seeking SAIOP program *

Substances Currently Used *

Primary Substance of Concern *

Age of First Use *

Frequency of Current Use *

Date of Last Use *

Previous Treatment History *

Longest Period of Sobriety *

Withdrawal Symptoms Experienced *

Impact on Life Areas *

Mental Health History *

Family History of Addiction *

Treatment Goals *

Motivation for Treatment *

Signature *

Clear Signature

Date *

Phone *