Court Ordered Substance Abuse Evaluation Intake Form

Contact Information

First name

Last name

Preferred Name

Age

Birthday

Preferred Pronouns

Phone

Country/Region

Address

City

Zip / Postal code

Court Order Information

Court Order Number

Probation Officer's First Name

Probation Officer's Last Name

Have you had any previous hospitalizations for mental health or substance use concerns?

Yes

If yes, please explain.

Are you currently taking psychiatric medications for:

Anxiety

Depression

Other

Please list your current medications:

Important Information

Court Ordered Anger Evaluations are $200 CASH only. $100 is due at the time of that the appointment is made and is non-refundable. The remaining balance is due at the time of your appointment. You must bring your Court Order documentation with you to your appointment. The report will be sent to the probation office within a few weeks.

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Court Ordered Substance Abuse Evaluation Intake Form

Contact Information

Court Order Information

Important Information