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A substance use assessment is the comprehensive clinical evaluation that establishes whether a substance use disorder is present, how severe it is, and which level of care fits. Behavioral health clinicians and alcohol and drug counselors complete one at entry to treatment, usually organized around the six ASAM Criteria dimensions. A typical substance use assessment runs 400 to 1,200 words.
Alcohol and drug counselors, therapists, clinical social workers, SUD program staff
Treatment team, medical directors, payers, utilization reviewers, auditors
400 to 1,200 words · 30 to 60 minutes by hand (clinical team estimate)
Intake and assessment documentation (compare: biopsychosocial assessment, intake note)
At entry to substance use disorder treatment, and when a level-of-care decision needs current clinical support
No federal law prescribes a format; state SUD licensure rules, Medicaid waivers, and payer contracts set the requirements, most of them built on the ASAM Criteria
A substance use assessment is the initial clinical evaluation that establishes whether a substance use disorder is present, documents the history behind it, and matches the client to a level of care. Clinicians also call it an SUD assessment, substance abuse assessment, chemical dependency evaluation, alcohol and drug assessment, or, where it drives placement, simply the ASAM assessment. That last name points to the organizing framework: the American Society of Addiction Medicine first published its patient placement criteria in 1991, renamed the work The ASAM Criteria with the 2013 Third Edition, and released the Fourth Edition in 2023. The criteria are copyrighted professional guidance, not law, yet an HHS review of state regulation found 45 states specifically use them for placement in SUD treatment, which is why most assessments walk the same six dimensions from withdrawal risk to recovery environment.
The most misunderstood rule around this document is 42 CFR Part 2. Part 2 is a confidentiality rule, not a content rule: it governs who may see SUD records created by a federally assisted program that "holds itself out as providing, and provides, substance use disorder diagnosis, treatment, or referral" (42 CFR 2.11), and it restricts use of those records in civil, criminal, administrative, or legislative proceedings against the patient. It says nothing about what the assessment must contain; content requirements come from state licensure rules and payers. The document itself is a specialized cousin of the biopsychosocial assessment: it covers the same biological, psychological, and social ground, then adds a substance-by-substance use history, an explicit withdrawal-risk review, and a level-of-care recommendation that the rest of the record must support.
The substance use assessment is the entry document wherever addiction treatment is organized as a program: outpatient and intensive outpatient SUD programs, residential treatment, withdrawal management, opioid treatment programs, and the SUD tracks of community behavioral health agencies. Alcohol and drug counselors write most of them, with therapists, clinical social workers, and program medical staff completing them where state rules allow. Referral sources vary widely, from a primary care screen to a family push, an employer, or a court, and the referral shapes what collateral the record needs. Two boundaries keep the neighbors straight. Upstream, a primary care or emergency setting runs a screening and brief intervention, and a positive screen refers out; the comprehensive assessment is this document, completed at the treatment program. Downstream from a general mental health intake, use this assessment when substance use is the presenting concern and a placement decision is needed; a practice whose client discloses moderate drinking inside therapy documents it in the intake note or biopsychosocial assessment instead, and a positive trauma screen along the way may call for a separate trauma assessment.
Identifying information and referral context. Client identifiers, date, clinician and credentials, service type, start and stop times, and who sent the client: a primary care screen, a family member, an employer, a court. Pitfall: leaving the referral source vague; it determines what collateral belongs in the record and who will be asking for a report.
Presenting problem in the client's frame. Why the client is here now, in their own words, plus what changed to prompt contact. Pitfall: recording only the referral reason; a client sent by someone else still has a frame of their own, and readiness planning starts from it.
Substance use history, substance by substance. For each substance: age of first use, current pattern with amount and frequency, route, date and amount of last use, longest abstinence, and prior treatment episodes with outcomes. Pitfall: collapsing everything into "polysubstance use"; without per-substance last use and amounts, neither the withdrawal-risk review nor the diagnosis has support.
Withdrawal risk and medical review. Current intoxication or withdrawal signs, any history of complicated withdrawal such as seizures or delirium, medical conditions, medications, and a standardized scale score where indicated. Pitfall: rating withdrawal risk low against a documented daily-use history with no scale score or vitals behind the rating.
Mental health and co-occurring screen. Psychiatric history and treatment, current symptoms with a screening score, brief mental status observations, and a suicide and violence screen with findings written out. Some state rules require this screen by name, with an approved tool. Pitfall: leaving the screen implicit when findings are negative; write the negative finding so the record shows you asked.
Readiness, relapse risk, and recovery environment. Stage of change anchored to a client statement or behavior, craving pattern, prior relapse circumstances, and the environment the client returns to: housing, work, relationships, supports, and exposure to use. Pitfall: recording readiness as a bare label; "contemplation" with nothing behind it tells the next clinician nothing about what to do with it.
Diagnostic impression with criteria. For each substance, the DSM-5-TR criteria met and the count, the severity that count supports, and the matching ICD-10-CM code, with remission specifiers where they apply. Pitfall: naming a severity with no documented criteria; the count is the evidence, and 2 to 3 criteria is mild, 4 to 5 moderate, 6 or more severe.
Level-of-care recommendation and dimensional summary. A rating or short narrative for each of the six dimensions, the recommended level of care that follows from them, alternatives considered, and the initial plan with referrals and consents. Pitfall: a placement no documented dimension supports; the medical-necessity chain for the whole episode starts at this paragraph.
Signature, credentials, and date. The assessing clinician's dated signature with credentials, plus co-signature where a trainee wrote it. Pitfall: treating the signature as a formality; under rules like Minnesota's, the assessment is not complete until a qualified staff member has dated and signed it.
Client: [initials] DOB/Age: Date: Clinician/credentials: Referral source: Service: substance use assessment Start/stop time: PRESENTING PROBLEM (client's words; why now): SUBSTANCE USE HISTORY (repeat per substance) Substance: Age of first use: Pattern / amount / frequency / route: Last use (date and amount): Longest abstinence + prior treatment and outcome: WITHDRAWAL RISK & MEDICAL REVIEW Current signs / scale score (e.g., CIWA-Ar): Complicated withdrawal history (seizures, delirium): Medical conditions / medications / allergies: MENTAL HEALTH & CO-OCCURRING SCREEN Psychiatric history / current symptoms + tool score: Suicide and violence screen (write negative findings): Mental status observations: READINESS (stage of change + client statement/behavior): RELAPSE RISK (craving pattern, prior relapse circumstances): RECOVERY ENVIRONMENT (housing, work, supports, exposure): STRENGTHS (what has worked; abstinence periods): DIAGNOSTIC IMPRESSION (per substance) DSM-5-TR criteria met + count; severity; ICD-10-CM code: DIMENSIONAL SUMMARY (ratings or narrative, Dimensions 1-6): LEVEL-OF-CARE RECOMMENDATION + rationale: Alternatives considered / barriers: INITIAL PLAN (referrals, consents, next appointment): Part 2 consent for disclosures reviewed/signed: [Y/N/NA] Consent to treatment reviewed and signed: [Y/N] Clinician signature/credentials: Date signed:
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: adult referred by his primary care provider to an outpatient SUD program after an elevated alcohol screen at an annual visit. All details are fictional.
Client: D.R., 34 · Date: 07/14/2026 · Clinician: M. Okafor, LADC · Service: Substance use assessment, 68 min, in office · Referral: Primary care provider · Start/stop: 09:03 to 10:11
Presenting problem: Referred after an AUDIT-C of 9 at his June physical. Client's frame: "the drinking crept up on me after my partner moved out." States he does not like where it is headed. Decided to follow through on the referral after canceling a morning with his daughter because he felt too rough to drive.
Substance use history: Alcohol: first use at 15; weekend use through his 20s; daily since early 2025. Current pattern 5 to 7 standard drinks most evenings, beer and whiskey, starting about 8 PM. Last use last night, 6 drinks, ending around 11 PM. Longest abstinence 6 months in 2022, self-directed, ended during a stressful job change. No prior formal SUD treatment. Reports morning shakiness after heavier nights, twice eased by a morning drink in the past month. Cannabis: first use at 17; currently vapes 2 to 3 evenings weekly; last use three days ago; has twice tried to cut back to weekends only and not held it; sees it as "not the problem." Other: denies tobacco, opioids, stimulants, sedatives, and hallucinogens; no injection use ever. Caffeine: two coffees daily.
Withdrawal risk and medical review: Mild morning tremor and sweats after heavier nights; no history of withdrawal seizures, hallucinations, or delirium. CIWA-Ar administered this morning = 4. BP 138/88, pulse 84. Hypertension diagnosed 2025, on amlodipine 5 mg; no other medications or allergies; last physical June 2026. No current intoxication observed. Ambulatory setting judged appropriate with daily check-ins during the first week of reduction; medical questions routed to his PCP.
Mental health and co-occurring screen: No prior psychiatric treatment or hospitalization. PHQ-9 today = 11, driven by sleep, energy, and mood items; item 9 = 0. Denies current suicidal ideation, intent, or plan; denies history of attempts and self-harm; denies thoughts of harming others. Mental status: on time, groomed, cooperative; speech normal rate; mood "flat lately"; affect congruent; thought process linear; insight fair and improving. Depressive symptoms to be re-screened after early abstinence rather than diagnosed today.
Readiness, relapse risk, and recovery environment: Preparation stage, anchored to conduct rather than a label: he called to schedule within two days of the referral and states "I don't want to be the dad who misses Saturdays." Craving strongest between 8 and 10 PM alone at home. Prior 6-month abstinence shows capacity; it ended without a support structure in place. Lives alone; brother 10 minutes away and aware; employed as an electrician with early starts; agreed to remove alcohol from the apartment this week. Exposure risk: solitary evenings, a poker group that centers on drinking.
Diagnostic impression: Alcohol use disorder, severe (F10.20): 6 criteria documented above (larger amounts over longer period, unsuccessful efforts to cut down, craving, tolerance, withdrawal, continued use despite the hypertension conversation with his PCP and the missed morning with his daughter). Cannabis use disorder, mild (F12.10): 2 criteria (unsuccessful efforts to cut down, larger amounts than intended). DSM-5-TR counts support each severity.
Dimensional summary and level of care: Dimension 1 (withdrawal): moderate; CIWA-Ar 4, no complicated-withdrawal history, manageable ambulatory with monitoring. Dimension 2 (biomedical): mild; hypertension, PCP engaged. Dimension 3 (emotional/behavioral): moderate; depressive symptoms to re-screen. Dimension 4 (readiness): engaged, preparation stage. Dimension 5 (relapse risk): high; nightly pattern, evening craving window. Dimension 6 (recovery environment): moderate; lives alone, supportive brother, stable work. Recommendation: intensive outpatient program, three evenings weekly, which places structure directly inside the high-risk window. Weekly individual outpatient was considered and set aside as insufficient against a nightly pattern. Client concurs; schedule fits his work hours.
Initial plan: IOP intake 07/16/2026. Part 2 consent for disclosure to his PCP reviewed and signed; program medical provider to discuss medication options for alcohol use disorder at intake; labs requested through PCP. Re-administer PHQ-9 and AUDIT-C at week 4. Brother identified as a support contact with client consent. Limits of confidentiality, program rules, and fees reviewed; consent to treatment signed. Assessment complete upon signature below. M. Okafor, LADC, signed 07/14/2026.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsBe precise about what 42 CFR Part 2 does, because most summaries are not. Part 2 protects the confidentiality of SUD records held by part 2 programs: federally assisted programs that hold themselves out as providing SUD diagnosis, treatment, or referral (42 CFR 2.11), which HHS has noted covers most SUD treatment programs. It controls consent and disclosure, and it restricts use of the records in civil, criminal, administrative, or legislative proceedings against the patient, protection that goes beyond HIPAA. The 2024 final rule (effective April 16, 2024, compliance required by February 16, 2026) lets patients sign a single consent for all future treatment, payment, and health care operations disclosures and gives HHS civil enforcement authority, including civil money penalties. What Part 2 does not do is prescribe one word of the assessment's clinical content, and a clinician outside a part 2 program is not under Part 2 at all, though HIPAA and state confidentiality law still apply. Write the assessment to clinical and payer standards; handle the finished record under Part 2's consent rules.
Content and deadline requirements live in state licensure rules and payer policy, and they are specific. LAW: Minnesota requires the comprehensive assessment face-to-face within five calendar days of service initiation for a residential program, requires a co-occurring mental health screen with an approved tool, requires risk ratings across the dimensions with an ASAM level-of-care recommendation, and deems the assessment complete only upon a qualified staff member's dated signature (Minn. Stat. 245G.05). LAW: opioid treatment programs must complete the full initial psychosocial assessment, care plan included, within 14 calendar days of admission (42 CFR 8.12). STATE AND PAYER POLICY: 45 states specifically use the ASAM Criteria for SUD placement, many through Medicaid 1115 demonstration terms (HHS ASPE, 2021), and with the Fourth Edition released in 2023, contracts can reference different editions; confirm which edition each state rule and payer contract names before you build the form around one. The general shape holds here as everywhere: the format is a convention; the content is the requirement. The assessment then hands off to the treatment plan, and when the admission interview is billed as a psychiatric diagnostic evaluation, this document is the record behind the claim.
SUD documentation audits produce some of the worst compliance numbers in behavioral health. In a 2021 audit of Colorado's Medicaid opioid treatment programs (HHS-OIG A-07-20-04118), providers had billed almost 1.5 million services worth about $22.2 million over two years; of 100 sampled services, 21 complied with federal and state requirements and 79 did not, and OIG estimated about 79 percent of services statewide fell short. The deficiencies were documentation deficiencies: missing treatment plans, missing required signatures, missing signed consents, and services with no medical evaluation or initial assessment on file at all. The BastionGPT Clinical Advisory Board sees the same errors most often in substance use assessment reviews:
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Most substance use assessments run 400 to 1,200 words and take 30 to 60 minutes by hand. The time range is a clinical team estimate: no published study benchmarks completion time for this document specifically. No regulation in the US, Canada, or Australia sets a word count or page length; where rules exist, they set completion deadlines and content requirements instead, program by program. Write to what the document must support: the diagnosis with its criteria, the withdrawal-risk finding, and the level-of-care recommendation.
No federal law requires it. The requirement, where it exists, comes from your state and payers: an HHS ASPE review found 45 states specifically use the ASAM Criteria for placement in SUD treatment, many through Medicaid 1115 demonstration terms, while New York developed its own level-of-care tool, LOCADTR. Where ASAM is named, document every dimension: research on structured administration reported an intraclass correlation of .77 for level-of-care assignment, and the dimensional narrative is what utilization reviewers actually read.
No. Part 2 governs consent and disclosure for records held by federally assisted SUD programs; it imposes no content requirements on the assessment itself. The 2024 final rule modernized the consent side: one signed consent can now cover all future treatment, payment, and health care operations disclosures, compliance was required by February 16, 2026, and HHS holds civil enforcement authority that includes civil money penalties. Write the clinical content to state and payer standards; apply Part 2 when the finished record moves.
The substance use assessment is the specialized version. It covers the same biological, psychological, and social ground as a biopsychosocial assessment, then adds a substance-by-substance use history, an explicit withdrawal-risk review, and a level-of-care recommendation tied to the six dimensions. General behavioral health settings lead with the biopsychosocial document and expand the substance section when a screen flags it; SUD programs lead with this one. In many agencies a single document serves both purposes, and reviewers care whether the required content is present, not which title sits at the top.
The document is not the code; the billed service is. Where the admission interview qualifies as a psychiatric diagnostic evaluation, it is commonly billed as 90791, and many state Medicaid programs pay the assessment under H0001. Keep the screening track separate: Medicare's timed structured-assessment and brief-intervention codes G0396 and G0397, and Medicaid's H0049 and H0050 where states adopt them, describe early-intervention services, not the comprehensive assessment. In Australia, MBS online lists no item for a standalone alcohol and other drug assessment as of July 2026; assessment work reaches Medicare there inside attendance and mental health items.
There is no general federal deadline; deadlines belong to program and state rules. Minnesota requires the comprehensive assessment face-to-face within five calendar days of service initiation for a residential program, excluding the day of initiation, and by the end of the fifth day on which a treatment service is provided in a nonresidential program. Opioid treatment programs must complete the full initial psychosocial assessment within 14 calendar days of admission under 42 CFR 8.12. Check your own state's SUD licensure chapter: the deadline attaches to your program type, not to the document's name.
State licensure decides, and Minnesota's rule shows the common shape: the comprehensive assessment may be administered by an alcohol and drug counselor, by a qualifying mental health professional with specific substance use disorder training, or by a clinical trainee practicing under supervision (Minn. Stat. 245G.05). Co-signature expectations follow the trainee and billing rules in your state rather than any national standard. The signature itself is not a formality: under rules like Minnesota's, the assessment is complete only upon a qualified staff member's dated signature.
The Third Edition (2013) established the six-dimension format most programs still use, and the Fourth Edition was released in 2023. Adoption runs through state rules, waiver terms, and payer contracts, and those references do not all update at once, so confirm which edition each state rule and each contract names, and document against that one. Whichever edition applies, the underlying content carries over: the per-substance history, the dimensional findings, and a placement rationale the findings support.
Yes. Paste the assessment interview transcript, dictate, or give it bullets, and it produces a structured draft with per-substance histories, the six-dimension summary, and the level-of-care rationale ready for your review. It can also fold screening scores, prior records, and collateral into the right sections. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.