Addiction Assessment Template

An addiction assessment template structures an intake or follow-up around substance use, withdrawal risk, level-of-care criteria, and safety, the details that decide where and how a patient gets treated.

Chris Hume
Head of Growth and Operations, JotPsych

Addiction medicine visits move fast and carry high stakes: a missed withdrawal symptom or an unasked question about lethal means can change what happens to a patient that day. A structured template keeps the visit organized around what the clinician needs to decide, not just what gets said. It fits addiction intakes and follow-ups, medication-assisted treatment visits, and any primary care or integrated behavioral health visit where substance use is the primary reason for the visit.

What the template captures

Substance use, cravings, and withdrawal

The template documents current and past use of alcohol, tobacco, cannabis, stimulants, opioids, and any other substance the patient reports, with the age of first use, the last use date, the pattern of use, any attempts to quit or cut back, and related complications for each one, plus prior substance use treatment. Craving intensity and frequency sit next to withdrawal symptoms, their duration, and their severity, because withdrawal risk sets the urgency and setting of care: severe alcohol or benzodiazepine withdrawal can be dangerous enough to require inpatient management.

Level of care under ASAM

The American Society of Addiction Medicine (ASAM) criteria set the standard for matching a patient to a level of care, from outpatient to residential treatment, across six dimensions. The template's ASAM section gives each dimension its own heading and prompts: acute intoxication and withdrawal potential; biomedical conditions and complications; emotional, behavioral, or cognitive conditions and complications; readiness to change; relapse, continued use, or continued problem potential; and the recovery or living environment. The note then shows why a patient meets a specific level, not only which level was chosen, so a payer that reviews the placement decision later can read the reasoning.

Safety assessment

This section separates suicidal and homicidal ideation (passive versus active, with or without a plan), prior self-harm or attempts, access to lethal means, and protective factors such as family support and treatment engagement. A separate section records the clinician's review of the state's prescription drug monitoring program (PDMP), the database that tracks a patient's controlled-substance prescriptions across pharmacies and prescribers: each controlled substance the patient was prescribed and the date it was last filled.

From assessment to diagnosis code

Once the picture is complete, the note still needs a diagnosis. The template's Billing Codes section suggests International Classification of Diseases, 10th revision (ICD-10) diagnosis codes and Current Procedural Terminology (CPT) codes for the visit, and names any code the visit nearly met, so the clinician checks the substance use diagnosis before signing the note.

The template in JotPsych is one of 25+ pre-built templates in the public library, alongside psychiatric intake, therapy, medication management, and CPT-coded visit templates. Selecting it before the encounter sets the structure, and the note's sections fill in from the recording as the visit happens. Editing a shared template never changes JotPsych's original: the first edit automatically creates the clinician's own copy, so customizing the template for a specific population does not touch the version the rest of the practice uses.

Source: JotPsych. Level-of-care criteria per the American Society of Addiction Medicine. Testimonial: JotPsych clinician feedback.