Patient Intake Form

Opioids Treatment

What substances are you currently using? (alcohol, drugs, prescription medications, etc.) How frequently and in what quantities do you use these substances?

Do you have any pre-existing medical conditions or take medications regularly? Have you experienced any physical health issues related to your substance use?

Have you ever been diagnosed with a mental health disorder? Are you currently taking any psychiatric medications? Have you ever received mental health treatment or counseling?

Does anyone in your family have a history of addiction or mental health issues? How would you describe your relationship with your family?

Can you describe your current living situation and any stressors you may be facing? Are there any social or environmental factors that you believe contribute to your substance use?

Have you ever faced legal problems as a result of your substance use? Are there any current legal issues you are dealing with?

Have you ever sought treatment for addiction before? If so, what types of treatment have you received, and what was your experience with them?

On a scale of 1 to 10, how motivated are you to make changes in your substance use? What are your short-term and long-term goals related to your health and well-being?

Who in your life is aware of your struggles with addiction? Do you have a support system in place, such as friends, family, or a mentor?

Have you experienced any traumatic events in your life that you believe may be connected to your substance use?

How do you typically cope with stress, anxiety, or difficult emotions? Are there healthier coping strategies you would like to explore?

Thank You!