Therapist's Guide to Clinical Intervention - Sigmund Freud

CHEMICAL DEPENDENCY ASSESSMENT
Date:
Name:
1. Description of Patient (identifying information):
2. Reason for Referral:
3. Patient's Perception of Chemical Use:
4. Patient's Treatment Expectations and Goals:
5. Effects of Lifestyle/Symptomatology:
A. Family (History of family problems in origin and/or present family including
chemical dependency);
Chemical Dependency Assessment 179