Addiction Assessment Template

What Is an Addiction Assessment Template?

Documenting addiction cases requires tracking a number of things: substance use patterns, withdrawal symptoms, safety concerns, and the social context that shapes recovery. And addiction assessment template is a structure which helps you keep every detail together and focus on your patients. Importantly, it can allow you to structure the assessment and not miss the details, organizing client information, substance usage history, technical criteria like ASAM, risk factors, prescriptions, and billing into a clear, linear path.

When Should You Use an An Addiction Assessment Template?

The Addiction Assessment Template is best used when:

• You’re conducting an addiction intake or addiction follow-up
• The patient’s substance use is a primary concern of the visit
• You’re creating or updating an addiction treatment plan
• You’re reviewing ASAM level of care to determine treatment setting
• You’re managing medication-assisted treatment (MAT)

This template fits cleanly into addiction medicine, primary care with a behavioral health focus, and integrated substance use disorder treatment settings.

How Should You Use an Addiction Template?

An addiction assessment template serves to both annotate and structure addiction-focused encounters. The template scaffolds the conversation and makes sure no clinically essential stones are left unturned. It captures:

• The why now (chief complaint, cravings, withdrawal)
• The clinical details (HPI, substance use history, ASAM criteria)
• The context (family, social, legal, medical history)
• The risk assessment (suicidality, homicidality, PMDP checks)
• The plan (treatment goals, patient education, interventions)
• The logistics (medication access, drug screen results, billing codes)

A template will help you hit relevant points and focus fully on your patient. For example, the template should help you parse information from the patient and narrativize it for the HPI, discern family and medical history, and find relevant billing codes, saving you the time of the writeup.

Key Sections of an Addiction Assessment Template

Substance Use

Documenting substance use patterns in detail is core to addiction assessment. An addiction template will help you capture:

• Substance type: Alcohol, opioids, stimulants, cannabis, etc.
• Route of administration: Oral, IV, smoking, intranasal, etc.
• Frequency and quantity: How often, how much, and in what pattern (binge vs. daily)
• Duration: How long the patient has been using each substance
• Time since last use: Crucial for withdrawal risk and safety planning
• Age of onset: Crucial context to understand in assessing severity
• Method of obtaining drug: E.g., street, prescription, family member, etc.

Clinician Tip:

Always drill into the context of use—what triggers the substance use? Is it tied to social situations, coping with mood, physical pain, or is it habitual? Understanding the functional role of the substance can guide more targeted interventions.

Cravings and Withdrawal

Cravings and withdrawal symptoms are explicitly tracked:

• Craving intensity: Patient-rated (e.g. 0–10 scale)
• Craving patterns: When are cravings most severe—morning, night, during stress?
• Withdrawal symptoms: Specifics like tremors, sweats, nausea, agitation, insomnia
• Onset/timing: When do withdrawal symptoms start relative to last use?

Clinician Tip:

Withdrawal risk dictates the urgency and setting of care. Severe withdrawal (e.g. alcohol, benzodiazepines) may require inpatient detox. Your notes should capture concrete symptom descriptions to back your level-of-care decision.

ASAM Criteria Assessment

The ASAM assessment supports level-of-care placement. An addiction template tracks:

• Dimension 1: Acute intoxication or withdrawal potential
• Dimension 2: Biomedical conditions and complications
• Dimension 3: Emotional, behavioral, or cognitive conditions
• Dimension 4: Readiness to change
• Dimension 5: Relapse, continued use, or continued problem potential
• Dimension 6: Recovery and living environment

Clinician Tip:

Don't just check the boxes—narratively explain why a patient meets a specific ASAM level (e.g. outpatient vs. residential). This protects your placement decisions and tightens your documentation for audits.

Safety Assessment

This section captures the patient’s suicide and homicide risk:

• Suicidal ideation: Passive vs. active, with or without plan
• Homicidal ideation: Targeted threats or vague ideation
• History of self-harm or suicide attempts
• Access to lethal means: Firearms, pills, etc.
• Protective factors: Family support, future goals, treatment engagement

Clinician Tip:

What patients mention in passing is important. The difference between “I wish I wouldn’t wake up” and “I have a plan to overdose” is critical. You should aim to document these nuances to support real-time safety planning.

What is an AI Scribe?

An AI scribe is an automated tool to simplify the process of note-taking and documenting patient encounters. An AI scribe will automatically convert rough notes into a structured record of the intake, documenting the specifics and filling out a template for you. The goal is that you handle the ideas and encounter, and the AI tackles the procedure.

JotPsych’s Addiction Assessment Template

What it is

JotPsych offers a comprehensive, AI-powered template to keep your addiction assessments in order. The template includes sections for HPI, substance use, withdrawal systems, sleep, prescription monitoring, family, medical, legal, & social history, and ASAM criteria among other systems.

How it Works

Before a patient encounter, you open JotPsych, select your addiction assessment template, and begin recording. The template has every section you should need in your intake, but can be easily customized if you find your encounters taking a different shape. To see how to create your first note, click here, and to see how to customize a template, click here.

When your encounter concludes, simply finish recording in JotPsych. Our AI will auto-populate the template with the relevant parts of your discussion, turning the conversation into notes automatically.

To see what a sample encounter looks like and how JotPsych turns any recording into a comprehensive note, click below.

Benefits of Using JotPsych’s Addiction Template

• Thorough documentation: No key elements missed, even in high-velocity visits
• Time savings: JotPsych sorts details into the correct sections in real-time
• Zero Notes Necessary: JotPsych goes straight from recording to documentation, without the need for you to annotate the conversation yourself
• Safety focus: Suicide risk, drug interactions, PMDP findings are always captured
• Treatment tracking: Goals and plans are front and center for seamless follow-ups
• Billing efficiency: Accurate coding without manual lookups

Customizing the Template

If your encounters differ from the structure of the template, JotPsych can still help! Just edit the template with sections that you want JotPsych’s AI to populate, and we’ll do the rest. To learn more about customizing templates, read here.

FAQ

Is submitting recordings to JotPsych secure?

Yes, it is! JotPsych takes extensive measures to remain HIPAA compliant and uses secure encryption to maintain the integrity of patient data.

What makes an addiction template unique?

An addiction template contains specific prompts and information that only comes up in addiction encounters. For example:

• Substance-specific prompts – It asks about route, dose, frequency, and last use for every drug class, so you’re not digging through free-text looking for “When did you last drink?”
• ASAM dimensions wired in – Patients are automatically and implicitly evaluated on the six ASAM dimensions based on their accounts.
• Safety shortcuts – Suicide, homicide, and overdose risk questions sit next to each other, with checkboxes for access to lethal means and protective factors.