Substance use assessment form
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Using a substance use assessment form to understand a client’s substance use history is a key part of the assessment process, which informs diagnosis and treatment planning.
This guide to substance use assessment forms gives mental health therapists a brief overview how to use substance abuse assessment forms, a sample template, and tips for working with clients who have substance use disorders.
You can also download a substance abuse assessment tools PDF to save to your electronic health record (EHR) to use with clients when necessary.
Assessing for substance use
The first step in assessing clients for substance use is to conduct a screening.
Clinicians use various screening and substance abuse assessment forms, depending on where they work and why the client is seeking treatment.
For instance, you may complete a brief screening as part of your overall biopsychosocial assessment.
If you are working in a primary care setting or a school, you may utilize more formal screening and assessment tools, including:
Biopsychosocial assessment
While understanding the client's biological, medical, and social history, you may also ask about the substances they use, their frequency, duration, context, and impact on their life.
Evidence-based screening tools
There are two types of validated screening tools: a pre-screening set of questions, and if the screening is positive, clinicians may progress to more detailed assessment tools.
Prescreening tools include:
- Screening to Brief Intervention (S2BI): A tool that assesses risky substance use, which improves outcomes for people who use substances.
- AUDIT-C is a pre-screening tool that asks clients about their drinking frequency and quantity.
- Tobacco, alcohol, prescription medication, and other substance use (TAPS): A tool that provides a two-stage assessment adopted from the NIDA quick screen and ASSIST-lite. This tool can be self-administered or administered by a clinician. It asks about substance use in the last 12 months.
- Opioid risk tool chart: This tool asks about family history of substance use, personal use history, and psychological disease.
- CAGE questionnaire: Asks a series of questions about attempts to reduce drinking, observations from others, feeling guilty about substance use, and needing alcohol to function.
- ASSIST-Lite: A brief version of the more detailed ASSIST test, which screens for using six commonly used substances.
Substance abuse assessment tools include:
- Alcohol, smoking, and substance abuse involvement screen test (ASSIST): Developed by the World Health Organization and a team of researchers to assess problem substance use in adults, this assessment includes eight questions about substance use outside of prescribed medications.
- Drug Abuse Screening Test (DAST-20): A test for adults and adolescents about their substance use that may be self-administered or provided by a clinician.
- TAPS: A more detailed substance use assessment form about use in the last 12 months.
DSM-5 criteria for substance use disorder
You could also use a DSM-5 substance use disorder worksheet with your client when the pre-screening questions are positive.
The specific DSM-5 criteria for substance use disorders* include:
A problematic pattern of substance use leading to clinically significant impairment or distress over the last 12 months, which includes at least two of the following criteria:
- Using more substance than intended or using it for longer than planned.
- Persistent desire to stop or unsuccessful attempts to cut down or stop using the substance.
- Spending a lot of time to obtain the substance, use it, and recover from its effects.
- Experiencing intense cravings or urges to use the substance.
- Recurrent use of the substance impacts daily life and the ability to fulfill obligations at home, school, or work.
- Continued use of the substance despite its effects.
- Substance use leads to giving up/reducing important social, work, or recreational activities.
- Recurrent use in dangerous situations.
- Using substances despite having physical or mental health conditions that will be negatively affected by substances.
- Increased tolerance to the substance, requiring more to have the same effect or less of an impact despite using the same amount.
- Withdrawal symptoms when not using the substance or the need to take other substances to relieve the withdrawal symptoms.
We’ve included these criteria in our substance abuse assessment template below.
*Note: This is a summary of the DSM-5 criteria. Additionally, the DSM-5 lists each substance use disorder separately for each substance—for example, alcohol use disorder, cannabis use disorder, etc.
Substance use assessment form template
The primary information to address in a substance use assessment form includes:
- Date of assessment
- Clinician name
- Client information (full name, date of birth, contact information)
- Prescreening tool(s) used, such as:
- Screening to Brief Intervention (S2BI)
- AUDIT-C
- Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS)
- CAGE Questionnaire
- Opioid Risk Tool Chart
- Other
- Results of prescreening (positive or negative)
- Detailed assessment tools used, such as:
- Alcohol, Smoking, and Substance Abuse Involvement Screening Test (ASSIST)
- Drug Abuse Screening Test (DAST-20)
- Detailed TAPS Assessment
- DSM-5 Criteria
- Other
- Assessment findings:
- History of substance use (including age substance use began)
- Substances used
- Frequency of use
- Duration of use
- Context of use (e.g., social, self-medicating)
- Impacts of substance use on daily life (work, social, recreational, physical health, and mental health)
- Attempts to quit
- Treatment recommendations and levels of care, such as outpatient counseling, mutual aid groups (SMART Recovery, LifeRing, Recovery Dharma, or 12-step programs), an intensive outpatient program, detox, or residential treatment.
We’ve included this information in a downloadable substance abuse assessment form at the top of this article, which contains a client-led screening form.
Tips for working with clients with substance use disorders
Working with clients who may have substance use disorder requires empathy, understanding, and compassion.
Here are some practical tips on how that might look in practice:
Build rapport with clients
Like any other assessment process, use a strengths-based and affirming approach, particularly around substance use, which may be a source of shame for the client.
Avoid centering your goals
Research shows that client-centered goals lead to more positive outcomes.
When collaborating on treatment planning, it’s important to consider that abstinence may not be the best approach for your client, and a harm reduction approach may be more effective.
There is also substantial evidence supporting the use of medication-assisted recovery as an effective treatment for opioid use disorders.
It may be helpful to be mindful of SAMHSA’s working definition of recovery when formulating goals.
SAMHSA defines recovery as: “A process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.”
Understand the range of options available
Recovery is not synonymous with 12-step programs. There are a range of recovery pathways, and Alcoholics Anonymous is just one of many programs. Others that are effective include SMART Recovery, LifeRing, Recovery Dharma, and Refuge Recovery.
Use client-led language
People who resolve an alcohol problem may not need to identify as being “in recovery.”
Research shows that around half of people who resolve a substance use issue do so without any formal treatment.
Be mindful of language
Research shows that words matter regarding substance use.
When clinicians use language like “substance abuser,” the client is less likely to get the treatment they need.
Additionally research has found that clinicians may be more likely to hold implicit and explicit biases that clients may benefit less from treatment and are more likely to be a social threat.
Instead, researchers recommend avoiding pejorative language and instead using person-first language like:
| Use | Instead of |
| Substance use disorders | Alcoholism or addiction |
| Person who uses drugs/alcohol | User, substance abuser, addict, alcoholic, “junkie” |
| Person in recovery or an individual who resolved a substance use disorder | Former addict or reformed addict |
| Recurrence of use | Relapse |
| Accidental drug poisoning | Overdose |
Sources
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Kelly, J. F., Bergman, B., Hoeppner, B. B., Vilsaint, C., & White, W. L. (2017). Prevalence and pathways of recovery from drug and alcohol problems in the United States population: Implications for practice, research, and policy. Drug and Alcohol Dependence, 181, 162–169.
- National Institute on Drug Abuse. (2023). Screening and Assessment Tools Chart.
- National Institute on Drug Abuse. (2021). Words matter - Terms to use and avoid when talking about addiction.
- National Institute on Drug Abuse. (2018). How effective are medications to treat opioid use disorder?
- New York State. (n.d.). SBIRT: Screening, Brief Intervention & Referral to Treatment.
- Recovery Research Institute. (n.d.). “Words Matter” When it Comes to Substance Use - Do Images Matter Too?
- Renger, S., Macaskill, A. Guided Goal Setting in Therapy Towards Being Fully Functioning. J Contemp Psychother 51, 357–364 (2021). University of Wisconsin-Madison. (n.d.). DSM-5 Checklist.
- Addiction Research Center.
- Substance Abuse and Mental Health Services Administration (2024). Harm reduction. https://www.samhsa.gov/find-help/harm-reduction
- Substance Abuse and Mental Health Services Administration (2024). Recovery and recovery support.
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