Free Substance Abuse Evaluation Template
Substance Abuse Evaluation
[YOUR COMPANY NAME]
Date: [DATE]
This comprehensive evaluation is meticulously structured to assess an individual's substance abuse history, behaviors, and pertinent factors. It aims to gather detailed information regarding substance use patterns, familial background, mental health status, legal entanglements, and treatment regimens methodically.
Evaluation Criteria:
1. Substance Use History:
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A thorough exploration of the individual's substance use history, encompassing types of substances, frequency, and severity of use.
2. Family History:
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Assessment of familial history with substance abuse to gauge potential genetic or environmental predispositions.
3. Mental Health History:
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In-depth evaluation of the individual's mental health status, focusing on any underlying conditions that may influence or exacerbate substance abuse tendencies.
4. Legal Issues:
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Examination of any legal entanglements directly or indirectly linked to substance abuse, including arrests, convictions, or pending legal matters.
5. Treatment History:
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Comprehensive overview of past treatment interventions, their efficacy, and current treatment plans, if any.
Evaluation Table:
|
Criteria |
Details |
Remarks |
Rating |
|---|---|---|---|
|
Substance Use History |
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Types of substances |
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Frequency of use |
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Severity of use |
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Family History |
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History of substance abuse in the family |
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Mental Health History |
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Existing mental health conditions |
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Legal Issues |
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Current legal issues related to substance abuse |
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Treatment History |
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Past treatment interventions |
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Efficacy of past treatments |
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Current treatment plans, if any |
Rating Criteria:
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1: Very Poor
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2: Poor
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3: Average
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4: Good
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5: Excellent
Additional Comments and Notes
|
Criteria |
Notes |
|---|---|
|
Substance Use Pattern |
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Family History |
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Mental Health Status |
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Legal Issues |
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Treatment History |
