Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
CRAFFT Adolescent Substance Abuse Screening
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Age
Alcohol Use in Past 12 Months
Cannabis Use in Past 12 Months
Other Substance Use in Past 12 Months
Ridden in a Car with impaired driver?
Additional details
Used substances to Relax?
Used substances while Alone?
Forget things while using substances?
Family or friends told you to cut down?
Gotten into Trouble while using?
CRAFFT Total Score
Confidentiality Acknowledgment
CRAFFT Adolescent Substance Abuse Screening template from formisoft.com. formisoft.com/intake-templates/crafft-adolescent-screening