Collateral Contact Note (SUD)

(Use neutral, behavioral language; attribute sources clearly; use direct quotes only for safety-critical or legally significant statements. Omit any section or field that does not apply.)

Date/Time of Contact: [Date and time]

Author: [Name, credentials, role]

Modality: [phone / video / in-person / secure message / other]

Direction: [inbound / outbound]

Duration: [Duration in minutes]

Collateral Name & Organization: [Name and organization if applicable]

Relationship to Patient: [family / friend / employer / probation or parole / healthcare provider / community agency / other]

Identity Verification: [Method of verification] (Briefly state how identity was confirmed, e.g., known contact on file, callback to agency main line.)

Consent & Disclosure Authorization

(Document the legal basis for any disclosure per 42 CFR Part 2. If consent cannot be verified, state that treatment status was not confirmed and disclosure was limited accordingly.)

• Consent status: [valid written consent on file / patient present and agreed / emergency exception / court order / no consent or consent not verified] (Include effective dates and scope if applicable.)
• Scope of permitted disclosure: [attendance only / treatment engagement / progress toward goals / full clinical status / medications / toxicology results / other]
• Information actually disclosed: [Explicit description of what was disclosed, or statement that disclosure was declined or limited]
• Criminal justice contacts: [Participation is condition of supervision: yes / no / unknown]; [Disclosure limited to progress monitoring: yes / no] (Include only for probation, parole, or similar; otherwise omit.)

Contact Summary

Purpose: [Reason for contact] (e.g., routine coordination, crisis, missed visits, relapse concern, return-to-work question, treatment transition)

Information Provided: [Information shared by clinician, including any education provided or confidentiality boundaries stated] (Ensure content aligns with permitted scope above.)

Information Received: [Information reported by collateral] (Attribute clearly using "Collateral reports..."; include timeframes and concrete observations; note any documents received; briefly note reliability concerns if relevant.)

Risk/Safety Concerns: [Concern identified, source, clinical determination, and actions taken with timestamps] (Include only if suicide, self-harm, violence, overdose, or child safety issues were raised; otherwise omit entirely.)

Clinical Interpretation: [How collateral information affects understanding of patient's current status, treatment engagement, recovery environment, or level-of-care needs] (Clearly distinguish interpretation from reported facts.)

Plan

Treatment Plan Changes: [Modifications to visit frequency, level of care, medications, family involvement, consents to obtain, or recovery supports] (State "No changes" if none.)

Follow-Up Tasks:

• [Task, responsible party, target date]
• [Additional tasks as needed]

Patient Notification: [Patient informed / will be informed at next visit / unable to reach]; [What will be reviewed with patient]

Signature

[Clinician name, credentials]

[Title, organization]

[Contact information]

[Date and time signed]