SUBSTANCE SCREEN
Rank Put in order of preference (1-primary, 2-secondary, etc.) If you have never used the substance, "NM" in the "rank" category. Frequency: How often this substance was/is used. (How many times per day, week, month, year, experimented...)
DRUG USED
RANK
FREQUENCY
METHOD
YEAR
1st
#YEAR
DATE LAST
Alcohol
USED
USED
USED
USED
Amphetamines
Barbiturates
Cocaine
Codeine
Crack
Demerol
Dilaudid
Glue
Hashish
Heroine
Barbiturates
LSD
Marijuana
Methadone
Methamphetamines
Morphine
Mushrooms
Other inhalants
PCP
Percodan
Quaaludes
Valium
Other (Please Specifiy)
ADJUNCTS
Please mark any court-ordered adjuncts that you are required to complete.
1=Meds to Reduce Alcohol UseName
6=Electronic Monitoring
2=Meds to Reduce Drug Use
7=Support Groups
3=Random UA's/Breath Testing
8=Opiod Maintenance Meds
4=VIP
9=Other
5=Interlock
10=Advance Directives
Adult Youth services Offer Interlock Enhancement Counseling. Please indicate if you are interested in attending these groups. Please fill out the bottom portion of this form by initialing either enrolling or decline. Please date by your initials.
Name:
Enrollment:
Decline Enrollment:
Continue
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15