Evidence-Based Guide to Creating a Pre-Assessment Form for Addiction Treatment

A pre-assessment form for addiction or substance abuse treatment is a vital tool for gathering critical information about a client’s background, substance use history, and treatment needs. Below is a step-by-step guide to designing an evidence-based pre-assessment form.

Sections and Key Questions to Include:

1. Personal Information

Collect basic demographic details to create a profile for the client.

• Full Name

• Date of Birth

• Contact Information (phone, email, address)

• Emergency Contact Details

• Preferred Pronouns

• Health Insurance Information (if applicable)

2. Presenting Problem

Identify the primary reason for seeking help.

• What brought you here today?

• What are your main concerns regarding your substance use?

• How has substance use affected your life (e.g., relationships, work, finances)?

3. Substance Use History

Understand the extent and pattern of substance use.

• Substances used (alcohol, opioids, stimulants, etc.).

• Frequency and quantity of use.

• Age of first use and duration of use.

• Method of use (oral, injection, smoking, etc.).

• Have you tried to stop or reduce substance use? If so, what happened?

4. Withdrawal History

Determine if the client has experienced withdrawal symptoms.

• Have you experienced withdrawal symptoms (e.g., tremors, sweating, nausea)?

• How do you manage withdrawal symptoms?

5. Mental Health History

Identify co-occurring mental health issues.

• Have you been diagnosed with a mental health condition (e.g., depression, anxiety, PTSD)?

• Have you experienced any of the following:

  • Mood swings

  • Suicidal thoughts or behaviors

  • Self-harm

  • Trauma (emotional, physical, or sexual)

• Are you currently on any psychiatric medication?

6. Physical Health

Understand the client’s physical health status.

• Do you have any chronic medical conditions (e.g., diabetes, HIV, liver disease)?

• Have you experienced overdoses in the past? If yes, how many times?

• Are you currently on any medications (prescription or over-the-counter)?

• Do you have any allergies?

7. Family and Social History

Explore the client’s relationships and support system.

• Describe your relationship with your family and loved ones.

• Does anyone in your family have a history of substance use or mental health conditions?

• Do you have a stable living situation?

• Who provides you with emotional or practical support?

8. Employment and Education

Assess the impact of substance use on work and education.

• Are you currently employed or in school?

• Have you experienced difficulties at work or school due to substance use?

• What is your highest level of education?

9. Legal History

Understand if legal issues are contributing to stress or barriers to treatment.

• Have you been arrested or faced legal issues related to substance use?

• Are you currently on probation or parole?

10. Motivation for Change

Gauge the client’s readiness for treatment.

• On a scale of 1–10, how motivated are you to stop using substances?

• What goals do you hope to achieve in treatment?

• What barriers or challenges do you think may interfere with your recovery?

11. Risk Assessment

Identify immediate risks to the client or others.

• Are you currently experiencing thoughts of harming yourself or others?

• Have you been involved in any dangerous behaviors while under the influence (e.g., driving, risky sexual behavior)?

• Do you have access to substances, weapons, or anything that could cause harm?

12. Treatment History

Gather information about past treatment experiences.

• Have you been in addiction treatment before? If yes:

  • Type of treatment (inpatient, outpatient, 12-step, etc.).

  • Duration and outcomes.

• Have you worked with a therapist or counselor before?

• What aspects of past treatments were helpful or not helpful?

13. Screening Tools

Include validated tools to standardize the assessment.

• AUDIT (Alcohol Use Disorders Identification Test) for alcohol use.

• DAST-10 (Drug Abuse Screening Test) for drug use.

• PHQ-9 (Patient Health Questionnaire) for depression.

• GAD-7 (Generalized Anxiety Disorder Scale) for anxiety.

• ACES (Adverse Childhood Experiences Scale) for trauma.

Additional Considerations

• Confidentiality and Consent: Include a section explaining the confidentiality of the form and obtain written consent for assessment and treatment.

• Cultural Sensitivity: Design the form to be inclusive and sensitive to cultural differences, language, and values.

• Accessibility: Ensure the form is available in multiple formats (e.g., paper, digital) and languages, if needed.

Formatting Tips

• Use simple, clear, and non-judgmental language.

• Incorporate open-ended questions to allow for detailed responses.

• Provide a mix of multiple-choice and free-text fields.

• Highlight optional vs. mandatory sections.

Sample Pre-Assessment Form Workflow

1. Client completes the form online or during their initial appointment.

2. The counselor reviews the form before the session to identify critical areas for discussion.

3. Use the pre-assessment to guide the first meeting, focusing on building rapport and clarifying client needs.

   
   

This evidence-based pre-assessment form ensures a holistic understanding of the client's situation, enabling tailored treatment plans and better outcomes.