Full Name: 

[Your Name]

Date of Birth: 

[Month Day, Year]

Gender: 

[Your Gender]

Contact Information: 

[Your Contact Information]

Emergency Contact:

[Name, Contact Information]

Marital Status:

[Your Name]

Living Arrangements:

[Renting an apartment]

Educational Background:

[Bachelor's degree in Business Administration]

Employment Status:

[Full-time employment]

Family Substance Abuse History:

[Father had a history of alcohol abuse]

Family Mental Health History:

[No known history]

Substance

Age of First Use

Frequency

Current Pattern

Previous Attempts to Quit/Cut Down

[Alcohol]

[18]

[Weekly]

[Social

drinking]

[No]

Current physical health status:

[Generally good]

Medications and medical conditions:

[No chronic medications, no significant medical conditions]

History of chronic pain or illness:

[None reported]

Presence of mental health disorders or symptoms:

[No formal diagnosis; occasional anxiety]

History of trauma or significant life stressors: 

[No reported history]

Coping mechanisms and strategies:

[Exercise, occasional journaling]

Current living situation:

[Renting an apartment alone]

Support system: 

[Limited family support; a few close friends]

Financial stressors: 

[Moderate financial stress due to student loans]

Peer influences:

[Some friends engage in substance use]

Access to substances:

[Easy access to alcohol and marijuana]

Workplace or school environment:

[Supportive work environment]

Willingness to make changes:

[Open to change; expresses desire to cut down on substance use]

Previous attempts at change:

[Attempted to quit marijuana without success]

External motivation factors:

[Concerns about impact on job performance]

Level of care recommended: 

[Outpatient counseling]

Referrals to other professionals or services:

[Referral to individual therapy for anxiety]

Initial treatment goals:

[Reduce alcohol use, develop coping skills]

Explanation of the purpose of the assessment:

[To inform treatment planning and provide appropriate support]

Consent for treatment and release of information: 

[Consent provided for treatment; no release of information at this time]

Counselor's observations and clinical impressions:

[Client appears motivated for change, insightful about substance use patterns.]

Additional recommendations for intervention or support:

[Explore stress management techniques; consider attending support groups.]

Proposed schedule for follow-up assessments:

[Bi-weekly for the first month, then monthly]

Contingency plans for crisis situations:

[Emergency contact provided; encouraged to seek immediate help if in crisis.]