Substance Use Disorder Intake Assessment | Comprehensive SUD Evaluation

The SUD Intake Assessment: Mapping the Full Picture of Substance Use

A substance use disorder intake assessment is a comprehensive interview that maps the client's relationship with substances — what they use, how much, how often, consequences, medical and psychiatric history, family history, and motivation for change. Unlike a screening tool that identifies the presence of SUD, an intake assessment gathers the detailed history needed to plan treatment. It captures the trajectory of use (when did casual use become problematic?), the patterns (daily use vs. binges?), the consequences (medical, legal, social, occupational), and the context (trauma, mental illness, peer influence). For clinicians, the assessment answers: What is the severity of this client's SUD? What is their readiness for change? What comorbidities need treatment? What assets do they have for recovery?

A thorough SUD intake is the foundation of all subsequent treatment. It reveals which clients need detoxification, which are at medical risk, which have severe psychiatric comorbidity, which have stable housing and employment, and which are highly motivated versus still in denial. It shapes the level of care (outpatient, intensive outpatient, residential) and the treatment modality (medication-assisted treatment, abstinence-based, harm reduction).

What is a substance use disorder intake assessment?

A SUD intake assessment is a detailed clinical interview covering the client's use history, consequences, medical and psychiatric status, family history, previous treatment, social/occupational functioning, and motivation for change. It is typically 60–90 minutes long and serves as the blueprint for all subsequent treatment planning.

What goes in the template

A comprehensive SUD intake includes:

Demographic Information: Name, age, contact, insurance, emergency contact, referral source.

Chief Complaint/Presenting Concern: Why is the client here now? Self-referred, family/legal pressure, employer referral, medical complications?

Current Substance Use:

• Primary substance of concern
• Frequency of use (daily, several times weekly, binges)
• Quantity per use or per week
• Route of administration (oral, nasal, inhalation, injection)
• Age of first use and age when use became problematic
• Current abstinence status (currently using, recently stopped, period of sobriety)

Polysubstance Use (if applicable):

• Secondary and tertiary substances
• Consequences specific to each substance
• Whether any substance is primary versus secondary

Consequences of Use:

• Medical: Medical complications (liver disease, respiratory issues, cardiac issues, overdoses, injuries), emergency room visits, hospitalizations
• Psychiatric: Symptoms (depression, anxiety, psychosis, memory problems, cognitive impairment), psychiatric diagnoses, medication history
• Social: Damaged relationships, isolation, loss of friends, conflict with family
• Occupational: Job loss, financial difficulties, inability to work, school dropout
• Legal: Arrests, DUI, incarceration, probation/parole status
• Housing: Homelessness, unstable housing, housing loss due to use

Medical History:

• Chronic medical conditions
• Current medications
• Allergies
• Surgical history
• Last medical checkup (and encourage current medical evaluation if not recent)
• Hepatitis C, HIV, other infectious disease screening status

Psychiatric History:

• Current psychiatric symptoms
• Psychiatric diagnoses
• Prior psychiatric hospitalizations
• Suicidal/homicidal ideation (current and history)
• Trauma history (ACEs, abuse, assault, combat, other trauma)
• Current mental health treatment (therapy, medication)

Family History:

• Family history of substance use disorder
• Family history of psychiatric illness
• Family history of suicide or self-harm
• Quality of current family relationships
• Family support for treatment

Previous Treatment:

• Inpatient/residential treatment history (dates, program names, outcomes)
• Outpatient treatment history
• AA/NA/mutual support group involvement
• Medications tried (naltrexone, acamprosate, buprenorphine, methadone)
• What worked and what didn't
• Reasons for prior treatment endings

Psychosocial Functioning:

• Employment status and history
• Education level and current education
• Housing stability
• Social support (relationships, community)
• Recreational activities (apart from substance use)
• Spiritual/religious life
• Strengths and skills

Triggers and Coping:

• Triggers for use (stress, emotions, people, places, times of day)
• Coping strategies used (healthy and unhealthy)
• High-risk situations
• History of relapse triggers

Motivation for Change:

• Readiness stage (precontemplation, contemplation, preparation, action, maintenance)
• Reasons for seeking treatment now
• Ambivalence about change
• Goals (abstinence vs. harm reduction vs. moderation)

Safety and Risk:

• Current suicidal/homicidal ideation
• Medical risk from current use or detoxification
• Overdose history and risk
• Access to means if suicidal

Medical/Psychiatric Referrals Needed:

• Addiction medicine evaluation for medication-assisted treatment
• Psychiatric evaluation for comorbid mental illness
• Medical evaluation (physical exam, labs, imaging if indicated)
• Infectious disease screening

When to use the SUD intake assessment

• Every client beginning substance use disorder treatment
• Addiction medicine or psychiatry programs
• IOP, PHP, residential SUD programs
• Court-mandated treatment
• Workplace assistance programs (EAP)

How to use the SUD intake assessment with Scriber

During session: Use the assessment to gather comprehensive history in a structured way. The assessment provides a roadmap; you can adapt the order and depth based on what the client shares.

After session: When you record and transcribe with Scriber, the entire intake conversation is captured in the transcript. Scriber's clinical AI can extract:

• Substances used, frequency, quantity, routes of administration
• Consequences documented (medical, psychiatric, social, occupational, legal, housing)
• Medical and psychiatric comorbidities
• Family history and support
• Prior treatment history and outcomes
• Motivation for treatment and readiness stage
• Risk factors (suicide, overdose, medical complications)
• Referrals needed (addiction medicine, psychiatry, medical)
• Treatment plan recommendations based on intake findings

Scriber auto-generates a comprehensive intake note that documents the full assessment — you don't transcribe the intake manually. The note includes treatment recommendations, level of care indicated, and referrals needed.

Sample SUD intake summary

Client: 42-year-old male, self-referred, seeking treatment for alcohol and opioid use disorder.

Current Substance Use:

• Alcohol: Daily use, 8–12 drinks/day, started at age 16, problematic use for 15 years
• Opioids: Prescribed oxycodone for back injury 5 years ago; now uses 40–60 mg daily, supplemented with heroin 2–3 times weekly (intranasal)
• Cannabis: Daily, 15 years, minimizes concern about cannabis use

Consequences:

• Medical: Liver enzyme elevation (ALT/AST >3x normal on recent lab), hepatitis C antibody positive (status unknown), multiple overdoses (last one 6 months ago, revived with naloxone), hospitalization for alcohol withdrawal
• Psychiatric: Depression, anxiety, PTSD from military service, no current treatment
• Social: Divorce 2 years ago (wife cited substance use), estrangement from adult children, few social connections outside using peers
• Occupational: Unemployed for 1 year; last job ended due to absence and poor performance
• Legal: DUI 3 years ago (served 30 days); probation ended; considering restitution from prior incidents
• Housing: Stable, renting apartment; in arrears $3,000 on rent

Medical: Type 2 diabetes (poorly controlled, A1C 8.5%), hypertension (on medication), no recent physical. Last medical checkup 3 years ago.

Psychiatric: Depression (moderate; not on medication despite prior antidepressant use), anxiety (associated with withdrawal), PTSD (military service, Iraq, IED blast with squad casualties), no current psychiatric treatment.

Family: Father deceased (age 68); mother living, limited contact; mother had alcohol use disorder, deceased from cirrhosis. One sibling, no contact. No spouse or children in supportive roles currently.

Prior Treatment: AA attendance 2 years ago (6 months, stopped due to lack of motivation); no inpatient or residential treatment; briefly tried naltrexone 2 years ago (stopped after 2 weeks).

Motivation: Motivation stage = Contemplation/Preparation. States he is "tired of this," concerned about health (liver disease scares him), wants to reconnect with children (wants grandchildren someday). Ambivalent about whether he can sustain abstinence; unsure about medication-assisted treatment; willing to try if recommended.

Risk: Denies current suicidal ideation but reports "not caring if I live or die." Overdose risk high (polysubstance use, recent overdose, prior naloxone reversal). Medical risk from possible withdrawal and liver disease.

Recommendations: Addiction medicine evaluation for medication-assisted treatment with buprenorphine or methadone; psychiatric evaluation for PTSD and depression; medical evaluation with labs (full LFTs, hep C confirmatory testing, CBC, metabolic panel); case management for housing/employment support; consider trauma-focused therapy once stable.

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Why comprehensive assessment matters

Substance use disorder never exists in isolation. A client with SUD has usually experienced psychiatric trauma, medical consequences, and social disruption. Treatment that addresses only the substance use while ignoring psychiatric illness or trauma often fails. A comprehensive intake maps all these domains and ensures that treatment addresses the whole person, not just the presenting substance.

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Download the SUD Intake Assessment template — PDF and DOCX formats available. Use as your intake interview guide for every client beginning SUD treatment. The template ensures comprehensive assessment and clear documentation.

Start a 7-day trial — Record your SUD intake interview, Scriber transcribes the full assessment, and auto-generates a comprehensive intake note with treatment recommendations, comorbidity identification, and referral needs.