Intake Assessment (Substance Use Disorder, Biopsychosocial)

Date/Time: [Encounter date and time]

Location: [Setting and site/department]

Modality: [in-person / telehealth / phone]

Clinician: [Name, credentials, role]

Sources of Information: [Patient report / Chart review / PDMP / Collateral (name, relationship)] [Reliability statement] (Include reliability qualifiers when relevant, e.g., limited by intoxication, cognitive impairment, acute distress.)

Confidentiality/Consent Status: [42 CFR Part 2 applicability] [ROI status: obtained / declined / on file / expired] [Consent for collateral contacts: yes / no / pending] (Document protections, consent scope, and any restrictions on information sharing.)

Presenting Concerns and Patient Goals

[Narrative summary of presenting concerns in patient's words when possible] [Patient-stated goals: abstinence / reduced use / safer use / stabilization / housing / legal compliance / family reunification / other] [Treatment preferences: medications / counseling / peer support / trauma-informed care / cultural or faith-based supports] [Immediate priorities for today] (Write 2–4 sentences. If goals not assessed due to barrier, state "Goals not assessed" with reason and plan to reassess.)

Safety and Triage

(This section documents time-sensitive risks. Use explicit Yes/No/Unknown/Declined responses with concise details. Do not leave blank; if unable to assess, document reason and safety actions taken.)

Current Intoxication or Withdrawal

• Patient assessable: [Yes / No / Unknown] (If No/Unknown, state reason and safety actions.)
• Substance(s) suspected or confirmed: [List]
• Last use: [Date/time or unknown]
• Observable signs: [Signs and severity; ability to participate in interview]
• Withdrawal history red flags: [Prior seizures / Delirium tremens / ICU-level withdrawal / Complicated benzodiazepine withdrawal / None / Unknown]
• Structured tool: [Tool name, score, clinical interpretation] (Do not list item-by-item.)
• Immediate management needs: [None / Monitoring / Medication-assisted withdrawal / Referral to ED or detox]

Overdose Risk and Naloxone

• Prior overdose(s): [Yes / No / Unknown] (If Yes, approximate timing and circumstances.)
• Current risk factors: [Fentanyl exposure / Polysubstance use (opioids with sedatives or alcohol) / Using alone / Recent abstinence or tolerance loss / Homelessness / Recent incarceration / None]
• Naloxone status: [Has / Needs / Declined] (Document education provided, prescription issued, training for family or supports if applicable.)

Suicide and Self-Harm Risk

• Screening tool: [Tool name] [Result: negative / positive / incomplete] (Do not transcribe items.)
• If positive or concern present: [Ideation, plan, intent, past attempts, risk factors, protective factors]
• Current risk level: [Low / Moderate / High / Unable to assess] [Rationale]
• Mitigation plan: [Safety plan / Lethal means counseling / Crisis resources provided / Observation / Referral to higher level of care / Emergency evaluation]

Violence Risk and Victimization

• Homicidal ideation or aggression: [Yes / No / Unknown] (Details if Yes.)
• Access to weapons: [Yes / No / Unknown]
• Domestic violence or sexual assault screening: [Positive / Negative / Declined / Unable to assess] (Document current safety and urgent needs.)
• Mandatory reporting triggers: [Child or elder abuse / Impaired driving intent / Specific threats / None identified] [Actions taken]

Substance Use History

(Document each substance used or clinically suspected using the format below. If a category was not assessed, document "Not assessed" rather than omitting.)

[Substance: Alcohol / Opioids / Benzodiazepines or sedatives / Stimulants / Cannabis / Nicotine / Other]

• Age of first use: [Age or unknown]
• Current pattern: [Amount, frequency, route]
• Last use: [Date/time or unknown]
• Longest abstinence: [Duration and what supported it]
• Tolerance and withdrawal: [Symptoms present / None / Unknown]
• Prior withdrawal complications: [Seizures / DTs / Severe withdrawal / None / Unknown]
• Consequences: [Medical / Psychiatric / Occupational / Relational / Legal / Financial]

(Repeat for each relevant substance.)

Polysubstance Patterns

[Combinations that increase risk, e.g., opioids with sedatives or alcohol; temporal patterns; using alone vs. with others]

Injection Use

(Include if applicable.)

• Injection history: [Yes / No] (If Yes, routes and substances.)
• Equipment sharing: [Yes / No / Unknown]
• Syringe service access: [Yes / No / Unknown]
• Complications: [Wounds or abscesses / Endocarditis / Cellulitis / None]
• Infectious disease risks: [HIV, HCV, HBV exposure context]

Recovery Supports and Triggers

Supports: [People, places, routines, community, mutual-help, faith or cultural resources]

Triggers: [People, places, conditions, emotional states]

Synthesis: [Brief summary identifying most impairing substances and highest acute risks; interpret toxicology in context of history and clinical presentation] (Do not infer diagnosis solely from toxicology results.)

Prior SUD Treatment and Recovery History

• Prior treatment episodes: [Detox / Residential / PHP or IOP / Outpatient / Peer recovery / Mutual-help; approximate dates, duration, completion status]
• What helped vs. barriers: [Facilitators and barriers such as transportation, cost, stigma, housing instability]
• SUD medications: [Buprenorphine / Methadone / Naltrexone / Acamprosate / Disulfiram / None; response, adherence, adverse effects, reasons stopped]
• Relapse patterns: [Precipitants, early warning signs, protective factors]
• Recovery capital: [Skills, routines, meaningful roles, supports, motivators]
• External records: [Reviewed / Requested from (source) / Not available]

Medical History

• Active medical problems relevant to SUD care: [Chronic diseases, chronic pain, sleep disorders, pregnancy status, seizure history, TBI, infectious disease history]
• Current medications: [Prescribed, OTC, supplements; adherence; controlled substances and prescribers]
• Allergies: [Allergies and reactions]
• Primary care linkage: [PCP on file / None] [Last visit] [Barriers to care]
• Infectious disease testing and vaccination: [HIV, HCV, HBV testing history; HBV and HAV vaccination status] (Include if risk factors present.)

(Focus on conditions affecting SUD treatment selection. Avoid exhaustive review of systems unless indicated.)

Psychiatric History and Mental Status

• Past psychiatric diagnoses: [Documented vs. patient-reported]
• Prior care: [Hospitalizations, ED visits, therapy, psychiatric medications with responses]
• Current psychiatric symptoms: [Mood, anxiety, psychosis, trauma symptoms, sleep, cognition, attention; severity and functional impact]
• Temporal relationship to substances: [Timing of symptoms relative to intoxication, withdrawal, abstinence periods] (Differentiate substance-induced vs. primary symptoms.)

Mental Status Examination

• Appearance and behavior: [Concise descriptors]
• Speech: [Rate, volume, fluency]
• Mood and affect: [Mood state; affect range, reactivity, congruence]
• Thought process: [Logical / Linear / Circumstantial / Tangential / Disorganized]
• Thought content: [SI, HI, delusions, preoccupations, or none]
• Perceptions: [Hallucinations, illusions, or none]
• Cognition: [Orientation, attention, memory as assessed]
• Insight and judgment: [Good / Fair / Limited / Poor] [Brief rationale]

(If trauma history is relevant, screen with permission; document patient preferences to avoid retraumatization. Avoid graphic detail unless essential for safety. If not assessed, state explicitly.)

Social History and Recovery Environment

• Living situation: [Housing type, stability, safety, cohabitants, substance exposure in home]
• Employment or education: [Status, schedule, risks or supports]
• Finances and insurance: [Coverage, medication access barriers, financial strain]
• Transportation and communication: [Phone access, transportation reliability]
• Food security and basic needs: [Stable / Unstable with details]
• Family and social supports: [Supportive persons, caregiving roles, children or custody considerations]
• Culture and identity: [Preferred language, cultural factors, sexual orientation and gender identity as relevant]
• Functional impact: [ADLs, occupational function, relational function]
• Specific impacts on treatment plan: [e.g., no safe storage for medications, unreliable phone, need for childcare, literacy or language needs]

Legal Involvement

(Include if current legal involvement is present; otherwise, omit this section.)

• Status: [Probation / Parole / Pretrial / Pending charges]
• Court dates and requirements: [Dates, mandated treatment requirements]
• Information sharing: [What can be shared, with whom, under what authorization]
• Forensic requests: [Drug test results / Attendance letters / Other; patient consent status and limits]

(Use neutral, factual language. Distinguish clinical recommendations from legal requirements.)

Objective Data

(Include when obtained.)

• Vitals: [BP, HR, RR, Temp, SpO2] [Date and time] (If declined or unavailable, note reason.)
• Focused physical exam: [Findings relevant to intoxication, withdrawal, injection-related complications, cardiopulmonary concerns, cognition]
• Laboratory and diagnostics: [Toxicology (matrix, presumptive vs. confirmatory), infectious disease labs, liver tests, pregnancy test as indicated] [Brief interpretation linking results to risks and plan]
• Testing status: [Obtained / Declined / Not indicated / Pending] [Follow-up plan if pending]

(Avoid pasting large unfiltered lab panels. Use neutral language for results.)

Biopsychosocial Synthesis and Level of Care

Problem summary: [Concise summary: most impairing substances, severity indicators, key complications, major psychosocial barriers and supports] (Every conclusion must be traceable to documented facts in earlier sections.)

Multidimensional risk assessment: (Adapt dimension labels to organizational standard, e.g., ASAM six dimensions.)

• Withdrawal potential: [Low / Moderate / High] [Rationale]
• Biomedical complications: [Low / Moderate / High] [Rationale]
• Psychiatric or behavioral complications: [Low / Moderate / High] [Rationale]
• Readiness and motivation: [Low / Moderate / High] [Rationale]
• Relapse or continued use potential: [Low / Moderate / High] [Rationale]
• Recovery environment: [Low / Moderate / High] [Rationale]

Level-of-care recommendation: [Outpatient / IOP / Residential / Withdrawal management (ambulatory or inpatient) / ED referral / Other] [Rationale] [Contingencies, e.g., if withdrawal worsens, refer to ED or detox] (If determination is outside scope, recommend formal placement evaluation.)

Diagnoses

• Substance-related diagnoses: [Diagnoses with severity and course specifiers (e.g., early or sustained remission, in controlled environment); note provisional or rule-out as applicable]
• Co-occurring psychiatric diagnoses: [Confirmed / Provisional; supporting data or need for further assessment]
• Medical diagnoses affecting treatment: [Relevant conditions]
• Data needed to clarify diagnoses: [Collateral records / Testing / Observation period / Follow-up assessment]

Problem List and Care Plan

(Organize by problem, ranked by urgency. For each problem, document specific interventions. Ensure every high-risk issue has a corresponding plan element or documented rationale for deferral.)

[Problem]: [Problem name, e.g., Alcohol withdrawal risk, Opioid use disorder, Suicidal ideation, Housing instability]

[Intervention and plan for this problem, which may include: safety actions, withdrawal management, overdose prevention, medications with consent documented, psychosocial interventions, referrals, monitoring plan]

[Problem]: [Problem name]

[Intervention and plan for this problem]

[Problem]: [Problem name]

[Intervention and plan for this problem]

Follow-up plan: [Next appointment timeframe] [Return precautions] [How to access urgent help] [Contingency if unable to attend]

Patient understanding: [Patient understands and agrees / Declines / Needs clarification] [Barriers and accommodations addressed]