Substance use assessment template

Substance Use Assessment

Chief Concern / Referral Reason
- Patient goals and reason for assessment (self-referred, mandated, medical referral, relapse, etc.).

Substance Use History
- Substances used (alcohol, opioids, stimulants, cannabis, sedatives, nicotine, others) with onset, pattern, quantity/frequency, and route.
- Last use for each relevant substance; periods of abstinence and what helped.
- Tolerance, withdrawal history, and overdose history if discussed.

Consequences & Functional Impact
- Medical, legal, occupational, relationship, and financial consequences.
- High-risk behaviors (driving, injecting, sharing equipment) as discussed.

Prior Treatment
- Detox, residential, IOP, outpatient, MAT, peer support, and response/relapse pattern.

Co-Occurring Mental Health
- Mood, anxiety, trauma, psychosis symptoms and relationship to use (primary vs substance-induced impressions when appropriate).

Mental Status / Observational Findings
- Appearance, intoxication/withdrawal signs, cognition, insight, and engagement.

Safety / Risk
- SI/HI, overdose risk, access to means, domestic safety, and risk formulation.
- Protective factors and supports (including sober supports).

Readiness & Barriers
- Stage of change, ambivalence, external pressures, and barriers to engagement.

Assessment
- Substance-related diagnoses and severity impression; co-occurring conditions.
- Withdrawal risk and recommended level of care rationale.

Plan / Recommendations
- Detox/MAT/referral needs, counseling modality, safety plan, toxicology if indicated, and follow-up.