Addiction Initial Assessment Therapy Note Template

Description:

This template provides a structured framework for therapists conducting an initial assessment with a client presenting with addiction issues, capturing critical details about substance use, co-occurring conditions, and readiness for change to inform a tailored treatment plan. It is designed to assess the scope and impact of addiction across physical, emotional, and social domains, with comprehensive guidance to ensure a thorough evaluation that supports recovery-focused intervention.

Note:

Use this template for the first session addressing addiction concerns. Adapt sections based on the client’s substance use profile, willingness to disclose, or co-occurring needs, maintaining a nonjudgmental and supportive approach.

Date: [Record the date of the initial addiction assessment session to mark the start of the client’s therapeutic record]

Client Name: [Enter the client’s full legal name for accurate identification and documentation]

Therapist Name: [Enter the therapist’s full name to establish accountability and authorship]

Age: [Note the client’s current age to provide context for addiction patterns and life-stage factors]

Consent and Confidentiality

[Document the client’s understanding and agreement to the therapy process, including confidentiality limits (e.g., mandatory reporting for harm), noting signatures or verbal consent per ethical and legal standards.]

Client Information

Client Name: [Enter the client’s full legal name as provided for clear record-keeping]
Date of Birth: [Record the client’s date of birth in MM/DD/YYYY format to confirm age and addiction timeline context]
Emergency Contact: [List the name, relationship, and contact information of an emergency contact for urgent situations]
Referral Source: [Note who referred the client (e.g., self, family, court), including the reason, to contextualize the assessment’s purpose]

Addiction History

Substance Use Profile: [Describe the types of substances used (e.g., alcohol, opioids), including age of onset, frequency, and method of use, to map the addiction’s scope.]
Progression and Patterns: [Record how use has evolved over time, including escalation, attempts to quit, and current patterns, to assess severity and chronicity.]
Previous Treatment: [Detail prior addiction interventions (e.g., rehab, AA), including duration, outcomes, and client perceptions, to understand past recovery efforts.]
Related Consequences: [Note physical, legal, financial, or social impacts of use (e.g., DUIs, job loss), to gauge the addiction’s toll on the client’s life.]

Current Functioning

Substance Use Status: [Document current use patterns (e.g., daily, binge), including last use and withdrawal symptoms, to assess immediate needs.]
Behavioral Observations: [Record in-session behaviors (e.g., agitation, lethargy) to provide a snapshot of addiction-related presentation.]
Emotional State: [Describe the client’s emotional condition (e.g., guilt, anxiety), to evaluate the psychological impacts of use.]
Functional Impairment: [Detail how addiction affects daily life (e.g., work, relationships), to measure disruption across domains.]

Co-occurring Factors

Mental Health History: [List past or current mental health diagnoses (e.g., depression), including relevance to substance use, to identify dual-diagnosis needs.]
Medical History: [Note physical health conditions or medications, including substance-related issues (e.g., liver damage), to assess overall health.]
Environmental Triggers: [Identify situational or emotional triggers for use (e.g., stress, peers), to understand contextual influences.]

Risk Assessment

Overdose or Health Risks: [Document overdose history, current risk factors (e.g., mixing substances), or medical emergencies, to prioritize physical safety.]
Self-Harm or Suicidal Ideation: [Record thoughts or actions related to self-harm or suicide, including triggers, to address psychological safety.]
Protective Factors: [Highlight factors reducing risk (e.g., sobriety motivation), to leverage in treatment.]

Strengths and Resources

Client Strengths: [Identify resilience, skills, or positive traits (e.g., determination), to support recovery efforts.]
Support Systems: [List supportive relationships or resources (e.g., sober friends, NA), to utilize in the recovery process.]

Goals for Therapy

Client Goals: [Describe the client’s recovery aspirations (e.g., “stop drinking”), capturing their motivation.]
Therapist’s Initial Goals: [Outline preliminary objectives (e.g., reduce use, build coping skills), to set a treatment direction.]

Next Steps

[Detail session frequency and format (e.g., weekly therapy), initial focus (e.g., harm reduction), and contact options, to establish a clear plan.]

Summary and Initial Impressions

[Summarize the therapist’s understanding of the client’s addiction, integrating use patterns, impacts, and strengths, to guide treatment.]

Plan for Treatment

[Outline the preliminary approach (e.g., CBT, Motivational Interviewing), focus areas (e.g., triggers), or immediate actions (e.g., detox referral), to initiate recovery.]