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Intake Questionnaire
Name: ___ Birthdate (mm/dd/by): ___ ID: ___
Cell Phone: ___
Class Year: FrSoJrSrGradHometown (city, state): ___Major:___GPA: ___Who referred you to counseling? ___
Reason for
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How to fill out substance abuse intake questionnaire
How to fill out substance abuse intake questionnaire
01
Start by providing basic information such as your name, date of birth, and contact information.
02
Answer questions about your medical history, including any past substance abuse issues and current medications.
03
Describe any current symptoms or issues related to substance abuse that you are experiencing.
04
Be honest and thorough when answering questions about your substance use history, including frequency and types of substances used.
05
Provide information about any previous treatments or therapies you have tried for substance abuse.
06
Sign and date the form to acknowledge that the information provided is accurate and complete.
Who needs substance abuse intake questionnaire?
01
Individuals seeking help for substance abuse issues.
02
Healthcare professionals conducting assessments or providing treatment for substance abuse.
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What is substance abuse intake questionnaire?
The substance abuse intake questionnaire is a form used by healthcare professionals to assess an individual's substance use history, severity of use, and potential treatment needs.
Who is required to file substance abuse intake questionnaire?
Individuals seeking treatment for substance use disorders are typically required to fill out the substance abuse intake questionnaire.
How to fill out substance abuse intake questionnaire?
To fill out the substance abuse intake questionnaire, individuals should provide accurate information about their substance use history, including types of substances used, frequency of use, and any previous treatment experiences.
What is the purpose of substance abuse intake questionnaire?
The purpose of the substance abuse intake questionnaire is to gather essential information that will help healthcare providers understand the individual's substance use patterns and develop an appropriate treatment plan.
What information must be reported on substance abuse intake questionnaire?
The questionnaire typically requires information on personal demographics, substance use history, medical history, mental health status, and any past treatment experiences.
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