Substance Use Assessment Template

## What's Included

The Substance Use Assessment Template is a comprehensive clinical tool designed to facilitate thorough evaluation and documentation of substance use patterns, related behaviors, and psychosocial factors. Key sections include patient demographics, substance use history (covering types of substances, frequency, quantity, duration, and routes of administration), and detailed screening for tolerance, withdrawal symptoms, and cravings. Additional components capture mental health status, co-occurring disorders, risk assessment for overdose or self-harm, and motivation for change. The template also provides structured fields for family history, social supports, legal consequences, and previous treatment attempts.

Further, the template incorporates standardized assessment scales such as the CAGE questionnaire, AUDIT, or DAST, along with space for clinician observations and clinical impressions. Treatment planning elements include goals, recommended interventions, referrals, and follow-up scheduling. This structured format ensures consistency and completeness in the clinical documentation of substance use assessments, supporting both diagnostic clarity and treatment planning.

## Who This Template Is For

This template is specifically designed for clinical professionals working in mental health and substance use treatment settings, including psychiatrists, clinical psychologists, licensed clinical social workers (LCSWs), addiction counselors, nurse practitioners, and behavioral health clinicians who conduct substance use evaluations and treatment planning.

## How to Use

Begin by collecting comprehensive patient history and current substance use information, systematically entering responses into the corresponding fields to ensure no critical areas are missed. Utilize the included standardized screening tools to quantify substance use severity and related risks. Clinicians should document mental status findings and any co-occurring psychiatric symptoms to inform differential diagnosis.

After completing the assessment sections, use the treatment planning portion to outline individualized goals and interventions, referencing clinical observations and patient motivation. Ensure documentation is updated regularly to reflect changes in substance use patterns or treatment response. This template supports efficient yet detailed clinical documentation that meets both clinical and billing requirements.

## Customize with MentalNote

Using MentalNote, clinicians can automate the generation of this Substance Use Assessment Template directly within Microsoft Word by leveraging AI-driven prompts tailored to mental health documentation. MentalNote’s intelligent system streamlines the data entry process, suggesting relevant clinical fields and dynamically adapting to input, thereby enhancing accuracy and saving time. This integration allows for easy customization, enabling clinicians to modify sections or add specific questions relevant to their practice while maintaining standardized, high-quality documentation.