Patient Forms - Alcohol and Drug Dependency Services of Southeast Iowa

Dear Client: We are glad you are here to visit us. You can use the links below to fill out forms before you visit us in the office. Please read the instructions below carefully. If you have any questions, don’t hesitate to call in for assistance or email us at information@addsiowa.org.

The information you provide us is confidential, will be used to help us serve you, and will not be shared with any third parties unless you give us permission to do so.
To complete the forms, click on the form names below and a new window will pop up.
Fill out each form COMPLETELY. Make sure to scroll through the whole form. Any questions, please ask! No signatures are given, yet.
When you are done, click SUBMIT at the bottom of the form.
After you complete each form, you will see a “return button.” Please do not use it, just click on the NextStep Forms tab to the top left of your screen.

Here for an evaluation? Please complete forms 1 – 5. Are you getting admitted today? Please complete forms 1-6.

Coronavirus (COVID-19) Screener – Required for all evaluations, and all admissions until further notice.

1. Additional Assessment

2. ACEs Questionnaire

3. Patient Health Questionnaire – 9 (evaluations only)

4. Alcohol Use Disorder Identification Test

5. Drug Abuse Screening Test

6. Activities of Daily Living

ADDS Release of Information

ADDS Criminal Justice Release of Information

Department of Corrections Referral Form for Substance Use Evaluations

Initial Client Information Form