Client Intake Form










Identify the Substance(s) you are Currently Concerned About

  Level of Concern  
Substance Low Medium High Date of last use?

Many people that come to our Agency have had problems with the following concerns. Please answer whether you have had anyof these concerns, as this will help us to give you the best support. After each of the following questions, please tell us the last time,if ever, you had the problem by answering whether it was: In the past month (4), 2 or 3 months ago (3), 4 to 12 months ago (2),1 or more years ago (1), or never (0)

1. When was the last time that... In the past month 2 or 3 months ago 4 to 12 months ago 1or more years ago never
a. you used alcohol or drugs weekly or more often?
b. you spent a lot of time either getting alcohol or getting other drugs, using alcohol or other drugs, or recovering from the effects of alcohol or other drugs (e.g. feeling sick)?
c. you kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people.
d. your use of alcohol or other drugs caused you to give up or reduce your involvement in activities at work, school, home or social events?
e. you had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or you used any alcohol or drugs to stop from being sick or avoid withdrawal problems?
2. When was the last time that you had significant problems with... In the past month 2 or 3 months ago 4 to 12 months ago 1or more years ago never
a. feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future?
b. sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?
c. feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen.
d. becoming very distressed and upset when something reminded you of the past?
e. thinking about ending your life or committing suicide?
f. seeing or hearing things that no one else could see or hear or feeling that someone else could read or control your thoughts?
3. When was the last time that you did the following things two or more times? In the past month 2 or 3 months ago 4 to 12 months ago 1or more years ago never
a. lied or conned to get things you wanted or to avoid having to do something
b. had a hard time paying attention at school, work, or home
c. had a hard time listening to instructions at school, work, or home
d. had a hard time waiting for your turn
e. were a bully or threatened other people
f. started physical fights with other people
g. tried to win back your gambling losses by going back another day
4. When was the last time that you... In the past month 2 or 3 months ago 4 to 12 months ago 1or more years ago never
a. had a disagreement in which you pushed, grabbed, or shoved someone?
b. took something from a store without paying for it?
c. sold, distributed, or helped to make illegal drugs?
d. drove a vehicle while under the influence of alcohol or illegal drugs?
e. purposely damaged or destroyed property that did not belong to you?
5. When was the last time that you had significant problems with..(not related to alcohol or drug use) In the past month 2 or 3 months ago 4 to 12 months ago 1or more years ago never
a. missing meals or throwing up much of what you did eat to control your weight?
b. eating binges or times when you ate a very large amount of food within a short period of time and then felt guilty?
c. being disturbed by memories or dreams of distressing things from the past that you did, saw, or had happen to you?
d. thinking or feeling that people are watching you, following you, or out to get you?
e. video game playing or internet use that caused you to give up, reduce, or have problems with important activities or people at work, school, home, or social events?
f. gambling that caused you to give up, reduce, or have problems with important activities or people at work, school, home or social events?