Comprehensive addiction assessment and substance use disorder evaluation
Healthcare template · 17 fields (9 required) · ~4 min for respondents to complete · Free plan · No credit card · Fully customizable
About this form
Comprehensive addiction assessment and substance use disorder evaluation.
This template ships with 17 fields, ready to use as-is or as a starting point. Open it in the editor to add, remove, or reorder fields, match it to your brand, then share a link or embed it on your site — no code needed.
Every field, explained
Patient Name (Name, required)
Date of Birth (Date, required)
How did you come to treatment? (Single choice, required)
Primary Reason for Seeking Treatment (Long text, required)
Substances Currently Used (Multiple choice)
Primary Substance of Concern (Short text, required)
Age of First Use (Single choice, required)
Frequency of Current Use (Single choice, required)
Date of Last Use (Date)
Previous Treatment History (Multiple choice)
Longest Period of Sobriety (Single choice, required)
Withdrawal Symptoms Experienced (Multiple choice)
Impact on Life Areas (Multiple choice)
Mental Health History (Multiple choice)
Family History of Addiction (Multiple choice)
Treatment Goals (Long text)
Motivation for Treatment (Single choice, required)
Frequently asked questions
Is the Substance Abuse Intake Form template free?
Yes. The free plan includes 5 active forms and 100 responses a month, with no credit card required. Responses over the limit are held — never lost — and unlock when you upgrade.
Can I customize the fields?
Yes — every field is editable. Add, remove, reorder, or restyle fields in the drag-and-drop editor, add conditional logic, and match the form to your brand.
How do I share the finished form?
Publish it to get a share link, embed it on your website, or generate a QR code. Responses arrive in your dashboard with email notifications, CSV export, webhooks, and Zapier.
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