SUBSTANCE 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]