About this template
An alcohol and drug evaluation form is a vital clinical instrument utilized by rehabilitation facilities, addiction counselors, and healthcare providers to assess patients seeking support. This structured assessment gathers comprehensive patient history, substance use patterns, legal and DUI background, and specific life areas impacted by addiction. Clinicians rely on this intake data to formulate accurate diagnoses, design personalized treatment plans, and coordinate care with legal or insurance entities.
Doc2Form transforms this critical screening process into a streamlined Google Form. Instead of dealing with cumbersome paper packets or restricted proprietary platforms, practitioners can seamlessly deploy this assessment directly through Google Workspace. Collected responses populate instantly in a secure spreadsheet, allowing care teams to review histories, analyze evaluation metrics, and maintain thorough documentation while keeping administrative overhead to a minimum.
Key features
- Capture complete patient demographic and contact details securely
- Document detailed substance use history and affected life areas
- Record legal background, including DUI history and arrest years
- Provide dedicated sections for clinical impressions and recommendations
- Collect digital acknowledgement dates and signatures for compliance
Use cases
Initial clinical assessments at substance abuse rehabilitation centers
Court-mandated alcohol and drug evaluations following DUI offenses
Outpatient counseling intake and mental health screening procedures
Case management documentation for social workers and healthcare provi…
Case management documentation for social workers and healthcare providers
What this form collects
- Case ID (Short answer)Enter the internal case or file number assigned to this evaluation.
- Full Name (Short answer)Enter your first, middle, and last name.
- Birth Date (Date)Provide your date of birth.
- Email Address (Short answer)Enter a reliable email address for ongoing communication.
- Phone Number (Short answer)Provide your primary contact phone number.
- Residential Address (Paragraph)Enter your current street address, city, state, and zip code.
- Occupation (Short answer)State your current occupation or employment status.
- Gender (Dropdown)Select your gender identity.
- DUI History Status (Multiple choice)Have you ever been charged with driving under the influence (DUI)?
- DUI Count and Arrest Year(s) (Paragraph)If applicable, list the total number of DUI offenses and the year of each arrest.
- Life Areas Affected (Checkboxes)Select all areas of your life that have been negatively impacted by alcohol or drug use.
- Evaluator Full Name (Short answer)Enter the full name and credentials of the evaluating clinician.
- Evaluator Email (Short answer)Enter the professional email address of the evaluator.
- Evaluator Phone Number (Short answer)Provide the office phone number for the evaluator.
- Evaluator Address (Paragraph)Enter the clinic or office address.
- Evaluator Impression & Recommendation (Paragraph)Summarize your clinical assessment findings, diagnosis, and recommended treatment program.
- Signing Date (Evaluated Person) (Date)Enter today's date confirming your submission of this evaluation.
- Signature (Evaluated Person) (Short answer)Please type your full legal name to serve as your electronic signature.
- Signing Date (Evaluator) (Date)Enter the date of clinical sign-off.
- Signature (Evaluator) (Short answer)Evaluator: Type your full name and credentials to authorize this assessment.
FAQ
What is an alcohol and drug evaluation form used for?
It is used by healthcare professionals and addiction counselors to gather a patient's substance use history, assess the impact of addiction on various life areas, review legal or DUI records, and record professional recommendations for treatment.
How can I customize this template for my clinic?
Once added to your Google Drive via Doc2Form, you can easily modify any question, add specific clinical screening scales, rearrange sections, or adjust the branding to match your practice.
Are the form responses secure and private?
Yes. All responses are saved directly to your organization's secure Google account, ensuring you maintain complete ownership and control over your patients' sensitive data.
Can I share this evaluation form with legal or insurance entities?
Yes, you can easily export responses as a PDF or share specific spreadsheet summaries with authorized legal representatives, courts, or insurance providers as required by patient consent.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.