Substance Use Counseling Session Progress Note

Date of Service: [date]
Session Time: [start time – end time]
Duration: [minutes]
Modality: [in-person / video / audio-only]
Provider: [name, credentials]
Service Type: Individual SUD Counseling
Supervision: [trainee name/role; supervising clinician name, credentials] (Only include if trainee provided the service under supervision.)
Interpreter: [language; modality] (Only include if an interpreter was used.)

Subjective

(Use neutral, person-centered language. Attribute patient-reported content; avoid assumptions or stigmatizing descriptors.)

[Reason for visit and interval since last session] (1–2 sentences.)

• Interval substance use status (Per patient report; address each substance relevant to treatment plan.)
  • [Substance]: [last use date]; [quantity/frequency]; [route if clinically relevant]
  • (Repeat for each relevant substance.)
• Cravings: [intensity, e.g., 0–10]; [duration/pattern]; [internal triggers]; [external triggers]
• Stage of change: [precontemplation / contemplation / preparation / action / maintenance / recurrence] (Include brief behavioral evidence supporting designation.)
• Current goal framing: [abstinence / reduction / harm reduction]
• Homework/practice since last session: [completed / partial / not completed]; [brief progress summary]
• Co-occurring symptoms impacting use/recovery: [mood / anxiety / sleep / pain / other] (Only include if applicable.)
• Patient quote: "[salient quote]" (Only include if it meaningfully captures motivation, ambivalence, or safety-critical content.)

Objective

(Include only clinician-observed or measured findings.)

• Mental Status Exam:
  • Appearance/Behavior: [description]
  • Speech: [description]
  • Mood/Affect: [stated mood / observed affect]
  • Thought process/content: [description]
  • Orientation: [description]
  • Insight/Judgment: [description]
• Signs of intoxication/withdrawal: [observed signs / none observed]; [impact on session or safety planning if present]
• Standardized measures: [measure name]; [score]; [interpretation] (Only include if obtained or reviewed this session.)
• Toxicology: [results]; [collection date]; [interpretation] (Only include if available or reviewed this session.)

Assessment

[Clinical summary linking interval use, cravings, and triggers to functioning and recovery progress]

• Stage of change formulation: [precontemplation / contemplation / preparation / action / maintenance / recurrence]; [movement in readiness since last visit]
• Progress toward treatment goals: [improved / stable / regression]; [brief explanation]
• Medical necessity: [current symptoms/impairments impacting health, safety, or function]; [why skilled counseling remains indicated]

Risk/Safety

(Address each domain explicitly. If all are negative, a brief statement is sufficient.)

• Suicidal or self-harm ideation: [denied / passive / active] (If present: [plan / intent / means / timeframe / protective factors].)
• Homicidal ideation: [denied / passive / active] (If present: [details].)
• Overdose risk: [low / moderate / high]; [specific risk factors]; [protective factors]; [actions taken if elevated]
• Withdrawal risk: [low / moderate / high]; [substances of concern]; [monitoring or referral plan if indicated]
• Means safety counseling: [completed / not indicated / declined] (Only include if applicable.)
• Level of care rationale: [rationale for current level of care] (Only include if elevated risk identified.)

Interventions & Response

• Therapeutic approaches: [motivational interviewing / CBT / relapse prevention / psychoeducation / harm reduction counseling / contingency management / other]; [techniques applied and clinical target]
• Patient engagement and response: [participation level]; [insight gained]; [skills practiced]; [commitments made]; [movement in readiness observed]
• Care coordination: [collateral contacts / referral linkage / prescriber communication] (Only include if applicable.)

Plan

• Patient goal for next interval: [goal statement]
• Homework/practice: [specific assignments tied to session interventions]
• Relapse prevention/coping plan updates: [new triggers, coping strategies, supports identified] (Only include if changes made.)
• Referrals/coordination: [MAT / higher level of care / peer support / psychiatry / medical]; [status and next steps] (Only include if applicable.)
• Overdose prevention: [education provided / naloxone prescribed or access confirmed / declined] (Only include if addressed.)
• Follow-up: [next appointment date/time]; [modality]

Provider Signature: [name, credentials] — [date/time signed]
Supervisor Cosignature: [name, credentials] — [date/time] (Only include if supervision required.)