Assessment and Treatment Recommendations Worksheet
Substance Use History
Drug First Use: Yes or No Pattern of use over time? Frequency of use in past month? Date/Amount of most recent use?
Follow-on question:
1) Have these drugs ever been used in combination?
Consequences
Physical Consequences (Describe the physical consequences the client has experienced from substance use)
Psychological Consequences (Describe the psychological consequences the client has experienced from substance use)
Medical Concerns (Describe any medical concerns that might relate to substance use)
Past Treatment History (Describe any past treatment history for substance use, mental health concerns, or other related issues)
Environmental Factors
Residential (Describe their living situation)
Social support system (Describe their social support system including: family, friends, social groups)
Family and Family History
Family History of Use (Describe if family members use or have a history of using substances)
Family Mental Health History (Describe if family members have a current or past history of mental health problems and/or treatment)
Current Additional Status To Consider
Educational (Describe client’s educational level and if they are currently in school)
Financial (Describe clients employment and financial situation)
Legal (Describe if client has current or past legal problems)
Motivation for Treatment (Describe if the client thinks they have a problem, if they plan to stop or reduce their use of substances, and why they are seeking treatment)
Recommended assessment measures (what additional assessments or tests would your recommend)
Clinical Assessment (Describe the clients diagnosis, if any. Support with evidence from client’s history and from scholarly literature—this should be one to two pages)
Treatment Recommendations (Provide treatment recommendations for this client. Be sure to consider: financial/insurance resources, willingness to change, culture and diversity, and severity of use. Support recommendations with evidence from scholarly sources. This should be one or two pages)
Ethical Considerations (Describe any ethical considerations relevant to this case. Include: Client confidentiality, multiple relationships, etc.)
