Substance Use Disorder Intake Assessment

Date/Time: [Date and time of assessment]

Clinician: [Name, credentials]

Setting: [clinic / ED / inpatient consult]

Modality: [in-person / telehealth] (If telehealth, document identity verification method and patient location)

Sources of Information

[Sources consulted] (List all: patient self-report; collateral contacts with permission status; records reviewed such as prior notes, PDMP, pharmacy records, labs. If sources were limited, state why.)

Reliability: [good / fair / limited] — [rationale] (e.g., due to sedation, intoxication, guardedness, distress, language barrier, or time constraints)

Consent and Confidentiality

• Consent for evaluation: [obtained / not obtained] (Reference stored consent forms if captured elsewhere)
• Testing consented: [urine drug screen / HIV / HCV / HBV / pregnancy / other] (Note whether each was accepted or declined)
• Confidentiality reviewed including limits: [yes / no]
• Authorization to communicate with outside parties: [yes / no] — [parties and purpose; releases signed or declined with scope]

Chief Complaint and Presenting Concerns

Chief Complaint: "[Patient's own words]"

Referral Source: [self-referred / ED / PCP / probation / family / employer / other] — [reason for referral]

[Narrative summary of presenting concerns] (Include current use pattern, immediate safety concerns such as withdrawal risk, overdose risk, and suicidality, recent precipitating events, functional impact on work, housing, parenting, and legal matters, and urgency of treatment. Use person-first, non-stigmatizing language; document ambivalence neutrally.)

Patient Goals and Preferences: [abstinence / reduction / unsure]; interest in medications: [yes / no / undecided]; preferred setting: [setting]; barriers: [identified barriers]

Substance Use History

(Document each substance separately. If a category was not assessed, state "Not assessed." If quantities cannot be precisely quantified, document best estimate with explanation.)

Alcohol

• Onset: [Age at first use]
• Typical pattern: [frequency, amount, context]
• Last use: [date/time]
• Longest abstinence: [duration] — [what helped]
• SUD indicators: [indicators present] (e.g., loss of control, time spent, craving, role impairment, social/interpersonal problems, hazardous use, continued use despite harm, tolerance, withdrawal)
• Complications: [complications if present] (e.g., blackouts, injury, legal issues; omit if none)
• Prior treatments: [medications tried and response] (e.g., acamprosate, naltrexone, disulfiram; include adherence, reason discontinued)

Opioids

• Onset: [Age at first use]
• Typical pattern: [frequency, amount, route, source] (Specify illicit vs prescribed/nonmedical)
• Last use: [date/time]
• Longest abstinence: [duration] — [what helped]
• OUD indicators: [indicators present]
• High-risk features: [features present] (e.g., injection use, needle sharing, wound/abscess history, using alone, fentanyl exposure, polysubstance use with sedatives, overdose history with number and naloxone/CPR administered, current naloxone access)
• Prior medications: [medications tried and response] (e.g., buprenorphine, methadone, naltrexone; include induction history, adherence, reason discontinued)

Benzodiazepines/Sedative-Hypnotics

• Onset: [Age at first use]
• Typical pattern: [agent, dose, frequency, route] — [prescribed / nonmedical]
• Last use: [date/time]
• Longest abstinence: [duration] — [what helped]
• SUD indicators: [indicators present]
• Complicated withdrawal history: [seizures / delirium / ICU admissions / none]
• Prior treatments: [taper protocols or other treatments tried and response]

Stimulants

• Onset: [Age at first use]
• Typical pattern: [agent, route, frequency, amount] (e.g., methamphetamine, cocaine)
• Last use: [date/time]
• Longest abstinence: [duration] — [what helped]
• SUD indicators: [indicators present]
• Complications: [complications if present] (e.g., cardiovascular, psychiatric, dental, skin)
• Prior treatments: [treatments tried and response] (e.g., contingency management, medications, psychotherapy)

Cannabis

• Onset: [Age at first use]
• Typical pattern: [frequency, amount, route, potency if known]
• Last use: [date/time]
• Longest abstinence: [duration] — [what helped]
• SUD indicators: [indicators present]
• Complications: [complications if present] (e.g., hyperemesis, cognitive symptoms; omit if none)

Nicotine/Tobacco

• Typical pattern: [product type, frequency, amount] (e.g., cigarettes, vape, smokeless)
• Withdrawal symptoms: [symptoms if present]
• Prior treatments: [treatments tried and response] (e.g., NRT, varenicline, bupropion)

Other Substances

[Other substance use history] (Include hallucinogens, inhalants, gabapentinoids, kratom, or others if relevant, using the same structure. If none, state "No other substance use reported.")

Withdrawal and Intoxication Assessment

• Current status: [intoxicated / in withdrawal / neither] — [signs and symptoms observed]
• Vital signs: [BP, HR, RR, Temp, SpO2] (If not obtained, state reason)
• Observed findings: [findings] (e.g., tremor, diaphoresis, pupil size, agitation, sedation, orientation)
• Standardized scoring: [tool and score] (e.g., CIWA-Ar, COWS; if not performed, state "Not performed")
• History of complicated withdrawal: [history] (e.g., alcohol withdrawal seizures, DTs, ICU admissions, benzodiazepine withdrawal seizures, precipitated opioid withdrawal; or "None reported")
• Withdrawal management determination: [monitored withdrawal at higher level of care / ambulatory withdrawal with close follow-up / no withdrawal management needed] — [rationale]

Prior SUD Treatment and Recovery Supports

• Prior treatment episodes: [treatment history] (e.g., detox, residential, IOP/PHP, outpatient; include dates, duration, outcomes)
• Recovery supports: [supports engaged] (e.g., mutual-help groups, recovery coaching, faith/community supports; note what was helpful)
• Harm reduction engagement: [engagement history] (e.g., naloxone access/training, syringe services, safer use practices)

Psychiatric History and Current Symptoms

• Current symptoms: [symptoms present] (Screen for depression/anhedonia, anxiety/panic, trauma-related symptoms, psychotic symptoms, mania/hypomania, sleep disturbance, cognitive concerns)
• Past psychiatric history: [history] (Include prior diagnoses, hospitalizations, suicide attempts, prior medications with response, therapy engagement)
• Substance-induced vs primary: [assessment] (If uncertain, label provisional with plan to reassess after stabilization)

Medical History

• Chronic conditions: [conditions] (Include chronic pain, liver disease, respiratory disease, seizure disorder, pregnancy)
• Medications: [current medications]
• Allergies/adverse reactions: [allergies] (Note reactions to addiction medications specifically)
• Infectious disease status: [HIV/HCV/HBV status and dates if known]; testing today: [offered and accepted / offered and declined / not indicated]
• Reproductive health: [pregnancy status; contraception] (If applicable)

Social History

• Housing: [stability, who patient lives with, substance use exposure in home]
• Safety concerns: [IPV, exploitation, other concerns] (If present)
• Support network: [family, friends, peer supports]
• Caregiving responsibilities: [parenting, other caregiving]
• Employment/education: [status and goals]
• Insurance/benefits: [coverage, transportation access]
• Legal involvement: [probation/parole, pending charges, court mandates]
• Strengths and recovery capital: [identified strengths]

Physical Examination

• General: [appearance, distress level, nourishment, hygiene]
• Neurologic: [tremor, gait, orientation, focal findings]
• Skin: [injection sites, wounds, abscesses, track marks]
• Other systems: [other pertinent findings] (As indicated)
• Signs of intoxication/withdrawal: [objective signs observed]

(If exam limited or not performed, state reason)

Mental Status Examination

• Appearance/behavior: [description]
• Speech: [rate, volume, fluency]
• Mood/affect: [reported mood]; affect: [range, reactivity, congruence]
• Thought process: [coherent / logical / goal-directed / disorganized]
• Thought content: [content] (Note SI/HI presence or absence; reference Risk Assessment if detailed there)
• Perceptions: [hallucinations, illusions, or none reported]
• Cognition: [orientation, attention, memory]
• Insight/judgment: [assessment]

Objective Data

• Toxicology: [specimen type]; [presumptive / confirmatory]; [results] (Use positive/negative terminology. Note how results inform care and any limitations such as detection windows.)
• Labs: [results or orders placed] (e.g., LFTs, CBC, CMP, pregnancy, infectious disease)
• PDMP: [date reviewed]; [relevant findings]

(If no objective data available, state "No objective data obtained at this visit")

Risk Assessment

Suicide Risk

• Screening: [tool used and result] (If applicable)
• Ideation/plan/intent/means: [findings]
• History: [prior attempts, self-injury]
• Protective factors: [factors identified]
• Risk level: [low / moderate / high] — [rationale]
• Safety actions: [actions taken]

Overdose Risk

• Risk factors: [factors present] (e.g., recent overdose, using alone, polysubstance use with sedatives, recent abstinence with tolerance loss, fentanyl exposure, lack of naloxone)
• Mitigation: [interventions] (e.g., naloxone prescribed/dispensed, training provided, safer use counseling)

Withdrawal Risk

• Alcohol/benzodiazepine: [risk level and factors] (e.g., history of seizures/DTs, current severity)
• Opioid: [risk level and factors] (e.g., current severity, precipitated withdrawal history)
• Medical complications: [risks] (e.g., dehydration, comorbidity-related risks)

Violence Risk

[Homicidal ideation: present / absent]; [weapons access]; [violence history] (Include only if clinically indicated)

Other Safety Concerns

[Other concerns] (e.g., ability to care for self, exploitation/trafficking, child/elder safety; include if raised, otherwise omit section)

Safety Plan and Disposition

• Interventions: [crisis resources provided, warm handoffs, means safety counseling, naloxone provided]
• Disposition: [safe for outpatient / referred to higher level of care] — [rationale]

Assessment

Diagnoses:

• [SUD diagnoses with severity and specifiers] (e.g., severe opioid use disorder, moderate alcohol use disorder in early remission)
• [Intoxication/withdrawal diagnoses if present]
• [Co-occurring psychiatric diagnoses] (Specify confirmed or provisional)
• [Relevant medical diagnoses]

Clinical Formulation: [Narrative synthesis] (Summarize substance use patterns and severity, immediate risks, contributing factors, protective factors, and rationale for recommended level of care. Use person-first language.)

Level of Care Determination: [Summary across ASAM dimensions: withdrawal potential, biomedical conditions, psychiatric stability, readiness/engagement, recovery environment, patient preferences and barriers] — Recommended level: [level of care] — [rationale]; patient willingness: [willing / ambivalent / reluctant]; access barriers: [barriers identified]

Plan

(Organize by problem in descending order of urgency. For each, provide brief assessment followed by specific interventions.)

[Problem 1: Primary SUD diagnosis]

• Medications: [medication plan] (Include medication selected, induction approach, dosing, monitoring, contraindications considered. If not initiating, document reason and alternative plan.)
• Psychosocial: [interventions] (e.g., counseling modality, groups, contingency management, recovery coaching, mutual-help linkage)
• Harm reduction: [interventions] (e.g., naloxone prescribed/dispensed, overdose prevention counseling, safer use education, syringe services referral)
• Withdrawal management: [plan if applicable] (Include level of care, medications, monitoring, return precautions)

[Problem 2: Co-occurring psychiatric condition]

• Assessment: [brief summary]
• Interventions: [plan] (e.g., medications, therapy referral, safety planning, coordination; if deferring, state rationale)

[Problem 3: Medical needs]

• Testing/orders: [labs, imaging, infectious disease screening]
• Referrals: [referrals with details] (Include program name, warm handoff status, information shared, consent basis)
• Preventive care: [vaccinations, health maintenance]

Care Coordination

[Referrals placed] (Include program, contact, warm handoff completion, purpose, information shared under consent); [transportation or support needs for accessing care]

Follow-Up

• Next appointment: [date/time or timeframe]
• Monitoring plan: [check-ins, lab follow-up, withdrawal monitoring]
• Return precautions: [symptoms requiring urgent evaluation]

(If any section was not assessed or deferred, state explicitly: "Not assessed," "Unable to assess due to [reason]," "Patient declined," or "Deferred to next visit.")