Intake Assessment (SUD Biopsychosocial)

Date of Service: [Date]

Start/End Time: [Start time – End time]

Location/Modality: [in-person / telehealth] (If telehealth, include platform and patient location)

Clinician: [Name, credentials]

Patient Name: [Full name]

DOB: [MM/DD/YYYY]

MRN: [Medical Record Number]

Sources of Information: [patient / medical records / PDMP / collateral contacts] (List specific records or contacts if available)

Reliability/Limitations: [Assessment of reliability and any limitations such as intoxication, withdrawal, cognitive impairment, guardedness, language barriers, or incomplete records]

Interpreter: [Interpreter used: yes / no; if yes, include language] (If not used, state "No interpreter used")

(For any header field where information is unavailable, enter "Unknown" or "Not assessed" rather than leaving blank.)

Consent and Confidentiality

• [Consent for evaluation obtained from: patient / guardian / other] (Include date/time; if not obtained, state reason and next steps)
• [Confidentiality and limits reviewed: risks of harm to self/others, mandated reporting, and court orders discussed]
• [Releases of Information obtained: entities and purposes authorized] (If none, state "None obtained")

Reason for Visit

[Presenting problem and reason for seeking care now] (2–4 sentences summarizing immediate precipitant such as overdose, relapse, legal mandate, family crisis, or discharge from higher level of care. Include referral source and patient's stated goals/preferences; use direct quotes when clinically meaningful.)

Current Symptoms and Functional Impact

[Current withdrawal symptoms, intoxication effects, cravings, mood/anxiety symptoms, sleep, appetite] (State severity and duration when available. If unable to assess due to acute intoxication or other factors, state explicitly.)

• Work/school: [Functional impact]
• Relationships/family: [Impact]
• Self-care/ADLs: [Impact]
• Housing: [Stability and safety]

Substance Use History

(Repeat the following subsection for each substance with current or past significant use. If information is unknown or not assessed, explicitly state so rather than leaving blank.)

[Substance Name and Primary Route]

• Age of first use and progression: [Onset, escalation pattern]
• Current pattern: [Frequency, amount, typical setting/context]
• Last use: [Date/time] and [Estimated time to withdrawal onset]
• Tolerance and withdrawal history: [Presence/absence; include seizures, delirium, hallucinosis if present]
• Consequences experienced: [Medical / psychiatric / legal / occupational / relational]
• Overdose history: [Number of events, naloxone reversals, ICU admissions] (Include approximate dates if available)
• Prior/current medications for addiction: [Medications tried with response, adherence, side effects]
• Periods of abstinence: [Duration, dates if known, and recovery supports that helped]

High-Risk Behaviors and Screening

• High-risk behaviors: [Using alone, sharing equipment, impaired driving, unsafe sex, other overdose risks]
• Screening tools: [Name, date, score, brief interpretation] (Do not reproduce copyrighted instruments)
• Toxicology: [Specimen type, collection method, observed/unobserved, interpretation] (Note that toxicology alone does not establish diagnosis)

Prior Treatment History

• Prior treatment episodes: [Detox, residential, PHP/IOP/OP, MAT/OTP, ED visits, hospitalizations with approximate dates, duration, outcomes]
• What helped: [Effective interventions and supports]
• What did not work: [Barriers and reasons for dropout/nonadherence]
• Mutual-help/peer supports: [AA/NA/SMART Recovery, sponsors/peer mentors]

Psychiatric History

• Past diagnoses: [Psychiatric diagnoses]
• Hospitalizations/crisis episodes: [Psychiatric hospitalizations, ED visits with dates if available]
• Medications: [Current and past psychiatric medications with dose, adherence, response]
• Therapy history: [Modalities tried and response]
• Self-harm/suicide attempts: [History, separate from current risk assessment]
• Family psychiatric history: [Relevant history]
• Diagnostic considerations: [Substance-induced vs. primary disorder uncertainties and reasoning]

Medical History

• Active problems/surgical history: [Medical conditions and surgeries]
• Current medications: [Including OTC and supplements]
• Allergies: [Allergies and reactions]
• Primary care: [PCP connection and last visit]
• Chronic pain: [History and current pain management] (If relevant)
• Seizure/TBI history: [If present]
• Pregnancy status: [If applicable]
• Infectious disease screening: [HIV, hepatitis status if available]

Trauma and Safety History

• Trauma exposure: [Childhood abuse/neglect, IPV, sexual trauma, combat, incarceration, significant loss] (Screen at high level; document if patient declines to discuss details)
• Current safety: [IPV risk, safe housing, safe contacts]
• Trauma-related symptoms: [Nightmares, hypervigilance, dissociation] (If present)

Social History and SDOH

• Housing: [Status and stability]
• Employment/income/education: [Current status]
• Insurance/benefits: [Coverage status]
• Transportation: [Access to care]
• Food security: [Status]
• Phone/internet: [Access]
• Family structure: [Caregiving responsibilities, custody concerns]
• Social supports: [Key relationships and resources]
• Cultural factors: [Identity, language, spirituality as defined by patient]
• Top barriers to recovery: [Key barriers identified]
• Top supports/strengths: [Environmental strengths]

(If SDOH domains not fully assessed, state explicitly and plan follow-up.)

Legal Involvement

(Include this section when legal issues are present; omit if none.)

• Current charges/proceedings: [Status]
• Probation/parole: [Status and conditions]
• Court-mandated treatment: [Requirements and pending hearings]
• Authorized contacts: [Probation officer, attorney] (Ensure ROI obtained)
• Incarceration/reentry: [Recent history and needs]

Mental Status Exam

• Appearance: [Grooming, dress, hygiene]
• Behavior/psychomotor: [Calm / agitated / retarded; tremor; tics]
• Eye contact: [Good / fair / poor]
• Speech: [Rate, volume, tone, fluency]
• Mood: [Patient's words, quoted when helpful]
• Affect: [Range, intensity, congruence, stability]
• Thought process: [Coherent / linear / goal-directed / circumstantial / tangential / disorganized]
• Thought content: [SI/HI, delusions, obsessions, preoccupations—specify presence/absence]
• Perceptions: [Hallucinations present / absent]
• Cognition: [Orientation, attention, memory as assessed]
• Insight: [Good / fair / limited]
• Judgment: [Good / fair / limited]
• Reliability: [Good / fair / limited]

Physical Findings and Objective Data

• Vitals: [Values if obtained]
• General appearance: [Signs of intoxication or withdrawal: tremor, diaphoresis, pupillary changes, psychomotor changes]
• Labs/tests: [Relevant results including pregnancy test if performed, with date]
• PDMP review: [Date reviewed and clinically relevant findings]

(Label findings as observed vs. reported when relevant.)

Risk Assessment

• Suicide risk: [Low / moderate / high] — [Ideation, intent, plan, means, past attempts, protective factors. Interventions today: safety plan, crisis line, ED referral, etc.]
• Violence/homicide risk: [Low / moderate / high] — [Threats, access to weapons, identified victims. Interventions today.]
• Overdose risk: [Low / moderate / high] — [Opioid use, polysubstance, using alone, prior overdose, naloxone access. Naloxone provided/prescribed: yes / no.]
• Withdrawal complications: [Low / moderate / high] — [Alcohol/benzodiazepine history, seizure/DT risk. Detox/medical monitoring plan.]
• Ability to care for self: [Low / moderate / high] — [Functional capacity, neglect concerns]
• Mandated reporting: [Concerns identified and actions taken] (If none, state "No mandated reporting concerns identified")

Safety Plan Summary: [Warning signs, coping strategies, safe contacts, professional resources, crisis services, follow-up plan. Document patient agreement or refusal. If patient refuses recommended care, document capacity assessment and alternative plan.]

ASAM Dimensional Summary

• Dimension 1 (Withdrawal/Medications): [Withdrawal risk, need for medical management, MOUD considerations]
• Dimension 2 (Biomedical): [Medical conditions affecting placement or requiring coordination]
• Dimension 3 (Psychiatric/Cognitive): [Psychiatric acuity, psychosis/mania risk, cognitive limitations]
• Dimension 4 (Relapse/Use Risks): [Triggers, cravings, overdose risk behaviors]
• Dimension 5 (Recovery Environment): [Housing safety, exposure to use, supports, legal pressures]
• Dimension 6 (Person-Centered): [Patient preferences, motivation, cultural factors, barriers to engagement]

Diagnostic Impression

• [Substance use disorder #1: substance, severity] — [Supporting evidence] [ICD-10]
• [Substance use disorder #2] — [Supporting evidence] [ICD-10] (If applicable)
• [Co-occurring psychiatric diagnoses: confirmed / provisional] — [Rationale]
• [Relevant medical diagnoses affecting treatment]
• [Differential considerations: substance-induced vs. primary psychiatric disorder and what would clarify]

Strengths and Protective Factors

• Personal strengths/recovery capital: [Prior successes, skills, values]
• Supportive relationships: [Key supports and community resources]
• Motivation/readiness: [Stage of change, patient-stated goals]

[Brief statement linking strengths to treatment approach and engagement plan]

Plan

Immediate Safety/Medical: [Urgent actions taken today: detox referral, ED transfer, naloxone provided, withdrawal monitoring, crisis safety plan]

Level of Care: [Recommended level with clinical rationale; patient preference and barriers to placement]

Medications: [Medication evaluation, MOUD initiation/adjustment, coordination with prescriber/OTP]

Psychosocial Treatment: [Recommended counseling approaches and frequency]

Care Coordination: [Tasks requiring ROI: PCP, psychiatry, probation/court, community resources]

Referrals: [Housing, benefits, DV resources, infectious disease care, vocational/legal services, peer support]

Follow-up: [Specific timeline, next appointment, responsible party for scheduling/outreach]

Patient Education: [Overdose prevention, naloxone training, warning signs reviewed, crisis resources provided]

(If patient declines recommendations: document risks explained, patient understanding, capacity assessment, alternative plan agreed upon, and follow-up safety steps.)

Clinician Signature: [Name, credentials]

Date/Time Completed: [MM/DD/YYYY HH:MM]