A substance use assessment records a person’s use, withdrawal risk, health, and circumstances, and ends in a diagnosis and a recommended level of care. Copy the free template, see an alcohol withdrawal and a fentanyl example, and check what goes in each part and how it maps to the ASAM dimensions.
Blank substance use assessment template
FreeSUBSTANCE USE ASSESSMENT Client: [Name, age, pronouns] Date and time: [Date, start time] Setting: [Outpatient, withdrawal management, residential, hospital, or justice setting; in person or video] Referral source: [Self, family, physician, emergency department, court, employer, or other] Others present: [Name and relationship, or none] Assessor: [Name, credentials] CONSENT Consent to assessment: [Explained and signed] Confidentiality: [Limits explained, including any extra protections for substance use records where you practice] Releases of information: [Who the client agreed you may contact or share with, or none] REASON FOR ASSESSMENT In the client's words: [Why now] Referral question: [What the referrer asked, and any deadline or legal requirement] Recent events: [Overdose, arrest, hospital visit, job loss, or other trigger] SUBSTANCE USE HISTORY For each substance: [Substance; age at first use; age regular use began; current pattern and amount; route; date and time of last use] Primary substance: [The one causing the most harm, in the client's view and yours] Longest time without use: [When, how long, what helped, what led back to use] Nicotine and other use: [Tobacco, vaping, cannabis, gambling] WITHDRAWAL AND MEDICATIONS Past withdrawal: [Symptoms; any seizures, delirium, or hospital stays during withdrawal] Current intoxication or withdrawal: [Signs now, breath alcohol if done, CIWA-Ar or COWS score and the time it was taken] Medications for substance use: [Buprenorphine, methadone, naltrexone, acamprosate, or other, current or past, and how they worked] Withdrawal risk: [Low, moderate, or high, and the reasons] PHYSICAL HEALTH Medical conditions: [Liver, heart, infections, wounds, pain, pregnancy, injuries linked to use] Medications and allergies: [Name, dose, prescriber; allergies with reactions] Recent tests: [Liver tests, infection testing, pregnancy test, with dates] Primary care: [Clinician and last visit, or none] MENTAL HEALTH AND COGNITION Psychiatric history: [Diagnoses, treatment, hospital stays] Current symptoms: [Mood, anxiety, trauma, psychosis, sleep, with scores] Suicide and self-harm: [Ideation, plan, intent, past attempts; whether any overdose was intentional] Cognition: [Memory, attention, or learning needs that affect treatment] PAST TREATMENT AND RECOVERY Previous treatment: [Program, setting, dates, completed or left early, what helped] Recovery supports: [Mutual help, peer support, faith community, or none] RISKS LINKED TO USE Overdose: [Past overdoses, using alone, mixing substances, recent drop in tolerance] Injection: [Now or past, sharing equipment, wounds, last HIV and hepatitis C test] Driving and safety: [Driving after use, injuries, unsafe situations] Return to use: [Cravings, triggers, what happened after past treatment] LIVING SITUATION AND SUPPORTS Housing: [Stable, temporary, or none; who lives there; substance use in the home] Family and supports: [Partner, children and custody, people who help] Work, school, and money: [Role, attendance, income] Legal: [Charges, probation, court requirements] Access: [Transportation, phone, childcare, schedule] READINESS AND GOALS How the client sees their use: [Concerns, reasons to change, reasons not to] Client's goals: [Stop, cut down, or reduce harm; what they want back] Preferences and barriers: [Setting, medication, schedule, language, culture] SCREENING AND TESTS Scores: [AUDIT, DAST-10, CIWA-Ar, COWS, PHQ-9, GAD-7, or other, with dates] Toxicology: [Urine drug test result, if done] DIAGNOSIS Substance use disorder: [Substance and severity: mild, moderate, or severe] Criteria met: [Number met in the past 12 months, and which ones] Other diagnoses: [Mental health, medical, or other substance use] LEVEL OF CARE AND PLAN Domain summary: [Need in each domain, mapped to the ASAM dimensions your program uses] Recommended level of care: [Setting and intensity, with the level number your program uses] Immediate steps: [Withdrawal management, medication start, naloxone, medical referral] Referrals: [Programs, prescriber, primary care, mental health, housing] Next contact: [Date, time, and with whom] Signed: [Assessor name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Community addiction program, intake assessment, in person, with the program nurse
54-year-old man referred by his family physician after abnormal liver tests. Came with his adult daughter. “I can’t stop on my own, and I’m scared of another seizure.” Drinking increased after his separation 18 months ago. Missed 3 days of work last month, and his supervisor smelled alcohol on him at work last week.
Alcohol: first drink at 15; weekends from 18; daily for about 6 years. Now a 750 mL bottle of vodka a day, about 17 standard drinks, plus beer on weekends. First drink around 7 a.m. “to stop the shakes.” Did not drink this morning because he was coming here; last drink about 11 p.m. last night. Longest without alcohol: 4 months, 5 years ago, after an outpatient program; started again after his mother died. Tobacco: 20 cigarettes a day since 16. No cannabis for 20 years; no other drugs.
Two years ago he stopped suddenly at home and had a generalized seizure on day 2; admitted to hospital for 3 days. Shakes, sweats, and poor sleep every time he tries to cut down. No past delirium or hallucinations. Today at 10:15 a.m., about 11 hours after his last drink: tremor in both hands, sweating, nausea, and anxiety; oriented, no hallucinations. Nurse: breath alcohol 0.00, HR 112, BP 162/98, temperature 37.4 °C, CIWA-Ar 19. Never offered medication for alcohol use. Withdrawal risk: high, given years of daily heavy drinking, a past withdrawal seizure, and moderate to severe signs within hours of his last drink.
Hypertension on amlodipine, taken most days. Fatty liver on ultrasound last year. Liver tests last month: AST 112, ALT 58, GGT 340. Healing cut on his left hand from a fall at work 6 weeks ago. No known drug allergies. Low mood and poor sleep for about a year; no past psychiatric diagnosis or treatment. PHQ-9 14. Denies suicidal thoughts now or in the past; no firearms at home. Memory gaps after heavy nights; cognition to be rechecked once withdrawal settles.
Seizure risk if he stops without medical care, and he lives alone. Drives a work van; admits driving the morning after heavy drinking, with no charges. The fall at work happened while hungover. No overdoses, no injection, and no other drugs.
Outpatient group program 5 years ago, completed 8 weeks, then 4 months without alcohol. Went to mutual-help meetings a few times; liked the group program more than the meetings. Never offered medication for alcohol use disorder.
Lives alone in an apartment. His daughter, 26, lives 20 minutes away and is supportive. Works full time as an electrician; his supervisor knows he is getting help and will hold his job while he is in treatment. No money or legal problems. Drives himself everywhere; his daughter can drive him this week.
“I’m done. I just can’t get through the shakes.” Wants to stop drinking completely, keep his job, and be well for his daughter’s wedding next spring. Open to medication. Worried about time off work; prefers evening treatment once he is back at work.
AUDIT 33. CIWA-Ar 19. PHQ-9 14. Alcohol use disorder, severe: 8 criteria met in the past year, namely drinking more and for longer than intended, failed attempts to cut down, much of the day spent drinking or recovering, craving, missed work, drinking despite liver damage and low mood, tolerance, and withdrawal. Tobacco use, daily. Depressive symptoms: reassess after 2 to 4 weeks without alcohol.
Domain summary: withdrawal, high need; physical health, moderate, with blood pressure and liver tests; mental health, moderate, reassess when sober; risks, high, with seizure and driving; environment, lives alone with a supportive daughter; preferences, ready to stop and wants to keep working. Recommendation: medically managed withdrawal in hospital, starting today. The nurse called the hospital withdrawal unit; bed at 1 p.m., and his daughter will drive him there. Handover sent: past seizure, CIWA-Ar 19, liver tests, blood pressure. Until admission: no driving, his daughter stays with him, and 911 if he has a seizure or becomes confused. After withdrawal management: intensive outpatient program, 3 evenings a week, to be confirmed at discharge; medication for alcohol use disorder, naltrexone or acamprosate, chosen with his liver tests in mind; nicotine replacement offered. Next contact: program counselor calls the unit on day 3 to plan discharge.
Outpatient addiction clinic, after an emergency department referral, in person
29-year-old woman referred by the emergency department after an overdose 4 days ago. A friend gave her 2 doses of nasal naloxone and called 911. She left the emergency department after 6 hours; the referral was faxed to the clinic. “That was too close. I need to get on something.”
Opioids: oxycodone prescribed at 22 after a car crash; pills from friends when the prescription ended; heroin at 24; fentanyl since 25. Now smokes fentanyl 6 to 8 times a day, about 1 gram a day, and injects 2 or 3 times a week. Last use 8 a.m. today, smoked, 5 hours ago. Benzodiazepines: pills sold as alprazolam twice in the past month; none since the overdose. Cannabis most evenings. Alcohol about once a month, 2 drinks. Vapes nicotine daily. Longest without opioids: 3 months at 27, on methadone.
Withdrawal usually starts a few hours after her last use: aching, diarrhea, vomiting, goosebumps, and no sleep. No seizures. Today at 1:10 p.m.: yawning, runny nose, restless, pupils normal. COWS 6. Methadone for 3 months at 27 controlled her cravings; she stopped when she moved and couldn’t get to the clinic every day. Has never taken buprenorphine; a friend had precipitated withdrawal on it, and she is afraid of that. Withdrawal risk: uncomfortable but not dangerous in itself; the main risk is using again to stop it.
Abscess on her left forearm 6 months ago, treated with antibiotics, now healed. HIV and hepatitis C negative 2 years ago. Pregnancy test today negative; not using contraception. No medications or allergies. No primary care clinician. Anxiety since her teens, with panic attacks; never treated. GAD-7 13. Childhood trauma mentioned, not explored today. Says the overdose was not intentional: she used a new supply, alone. Denies suicidal thoughts now or in the past; no past attempts.
Two overdoses, a year ago and 4 days ago, both when using alone with a new supply. Recent street benzodiazepines add to the risk. Injects with new needles from a harm reduction program; has shared cookers, not needles. Does not drive and has no license. Tolerance will fall if she stops and then uses again.
Five-day withdrawal management stay at 26; used again within a week. Methadone at 27, as above. Went to a peer group at a drop-in center a few times. No counseling.
Rents a room in a shared house; one housemate uses fentanyl, the other doesn’t. Her son, 6, has lived with her mother for a year; she sees him on Saturdays. Works 20 hours a week as a line cook and has missed shifts. No legal issues. Takes the bus; the clinic is 25 minutes away. Has a phone.
“I don’t want to die. I want my son to have a mom.” Wants to stop fentanyl now. Prefers buprenorphine so she doesn’t need a clinic visit every day, but is afraid of precipitated withdrawal. Wants to keep working and see her son more often.
DAST-10 9. COWS 6. GAD-7 13. Urine drug test positive for fentanyl and cannabis; negative for other opioids, benzodiazepines, and stimulants. Opioid use disorder, severe: 9 criteria met in the past year, namely using more than intended, failed attempts to cut down, much time spent getting and using, craving, missed shifts, use in dangerous situations, use despite two overdoses, tolerance, and withdrawal. Cannabis use, no disorder found today. Anxiety, with panic attacks, to be assessed further.
Domain summary: withdrawal, mild now and not dangerous; physical health, testing due and no primary care; mental health, anxiety needing assessment; risks, high overdose risk; environment, a housemate who uses, a supportive mother; preferences, outpatient care with buprenorphine. Recommendation: outpatient care with medication for opioid use disorder and weekly counseling. Seen by the clinic prescriber today: buprenorphine-naloxone with a low-dose start over 7 days, overlapping her current use, to avoid precipitated withdrawal; daily check-in calls this week. Methadone stays an option if cravings continue. Two naloxone kits given, one for the house, and she was trained to use them. Advised not to use alone and not to mix with benzodiazepines or alcohol. HIV, hepatitis B, and hepatitis C tests drawn; hepatitis A and B vaccines offered. Referred to primary care and to the clinic’s mental health service for her anxiety. Next contact: prescriber call tomorrow, clinic visit on day 3, first counseling session next week.
Why the person is here now, who sent them, and what the referrer needs back.
Avoid: Writing the referrer’s view as the person’s. Someone sent by a court or an employer may have different goals, and both belong in the record.
One line per substance, so withdrawal risk and the diagnosis read straight from it.
Avoid: “Drinks socially” or “uses daily.” Write amounts in standard drinks, grams, or the units the person uses, and say how they use.
Whether stopping is safe, and which medications are already in play. This part decides whether withdrawal management comes first.
Avoid: Treating alcohol or sedative withdrawal as a comfort issue. Both can cause seizures, so arrange a same-day medical assessment when the risk is high.
Conditions caused or worsened by use, and those that change the plan.
Avoid: Diagnosing depression or anxiety during heavy use or withdrawal. Record the symptoms, and plan to reassess after a few weeks without use.
The harms most likely to happen next if use goes on, and what you did about each.
Avoid: Listing risks with no action. Pair each one with a step: naloxone, testing, or an agreement not to drive.
Where and with whom the person lives, and whether that helps or hurts recovery.
Avoid: Recommending a program the person can’t reach. Note the practical barriers, because they decide what care is realistic.
What the person wants, in their words, and what they will take part in. Their preferences shape which level of care will actually work.
Avoid: “Not motivated.” Describe what the person wants and what they’re unsure about. A goal of cutting down is still a goal.
The diagnosis and its criteria count, and the level of care your ratings support.
Avoid: A severity label with no count. Write how many criteria were met and which, so the next clinician can check it.
Ask everyone who drinks or takes sedatives daily about past seizures, delirium, and hospital stays in withdrawal. A past complicated withdrawal is one of the strongest warnings for the next one.
When someone takes an opioid, sedative, or stimulant as prescribed under medical care, tolerance and withdrawal don’t count toward the criteria. Count only the criteria that apply to use outside the prescription.
Ask whether the person wanted to die, or didn’t care whether they woke up. Record their answer and your view, and assess suicide risk either way.
Anyone who uses opioids, or whose drugs may contain fentanyl, should leave with naloxone and know how to use it. Tolerance falls after withdrawal management, a hospital stay, or jail, and overdose risk is highest then.
“Recommend intensive outpatient” tells the receiving program nothing. Link the level to the needs you found in each domain, and say what would change it.
Vero Scribe writes the substance use assessment in your template from the session, with the client’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
A substance use assessment that uses the ASAM Criteria to match a person to a level of care. It rates need across six dimensions, from withdrawal and physical health to the person’s environment and preferences, then points to the least intensive setting that is still safe and effective. This template’s domains map onto those dimensions.
In the 4th edition, published in 2023: intoxication, withdrawal, and addiction medications; biomedical conditions; psychiatric and cognitive conditions; substance use-related risks; recovery environment interactions; and person-centered considerations. The 3rd edition had readiness to change as its own dimension; the 4th edition folds readiness into the others. Map each section of this template to the edition your program uses.
Count how many of the 11 criteria the person has met in the past 12 months. They cover loss of control, effects on daily life, risky use, tolerance, and withdrawal. Two or three is mild, four or five is moderate, and six or more is severe. Write the number and which criteria, not just the label.
A therapy intake screens substance use in a few lines among many topics. A biopsychosocial assessment covers every area of life and ends in a formulation. A substance use assessment goes substance by substance, rates withdrawal risk, counts criteria, and ends in a level of care, which is what an addiction program or a court referral needs.
Yes. Copy it, or download it as a Word or text file. No account needed.
One psychotherapy session: focus, interventions, client response, risk, and progress toward goals.
A CBT session in its own order: mood check, agenda, homework review, thought or exposure work, new homework, and feedback.
An EMDR session by phase: target, negative and positive cognitions, SUD and VOC, bilateral sets, closure, and reevaluation.
Data, Assessment, Plan: the three-part session note, with the line between facts and judgment made clear.
Goal, Intervention, Response, Plan: a progress note that opens with the treatment plan goal.
Assessments, follow-up notes, and care plans, drafted for your review.
Common codes for substance use disorders and the diagnoses that come with them.
Turn warning signs and supports into a plan the person keeps.
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