Substance use counseling notes have specific requirements that general therapy notes don’t. Use changes between sessions, stage of change shifts, relapse events, withdrawal risk, and overdose risk all need to be tracked explicitly. A note that says “client discussed drinking habits and was encouraged to reduce use” documents nothing clinically useful.

Short answer: substance use session notes must track use since last session (days, amounts, substances), current stage of change, cravings and triggers, specific intervention and rationale, safety (withdrawal, overdose risk, suicide risk), and any functional consequences of use. The template below covers all of these.

Why Substance Use Documentation Is Different

Three things distinguish SUD documentation from general therapy notes:

  1. Use is a measurable behavior — unlike mood or cognition, substance use can be tracked quantitatively. Track it. Days used, amounts, substances. Without a baseline, you can’t document progress.
  2. Stage of change determines the intervention — the same client can be in contemplation in January and action in March. Documenting the current stage explains why you did what you did.
  3. Safety risks are substance-specific — alcohol withdrawal is a medical emergency. Opioid use after a period of abstinence raises overdose risk. These require explicit documentation.

Tracking Use: Timeline Follow-Back Method

The Timeline Follow-Back (TLFB) is a structured recall method: client reports substance use day-by-day since the last session, often anchored to calendar events.

In notes, document the summary — not a day-by-day transcript:

USE SINCE LAST SESSION
Days since last session: ___  Days of use: ___
Substances used: ___________  Amounts: ___________
Change from last session: □ More  □ Less  □ Same  □ Abstinent
Context of use episodes: [where, with whom, emotional state]

Example:

“TLFB: 7 days since last session. Used 4 days (Mon, Wed, Fri, Sat). Primary: alcohol — 6-8 drinks/episode. Saturday: 12+ drinks following argument with partner. Down from 7/7 days last session. First abstinent days in 3 months.”

Stage of Change: Document and Match

StageWhat the client says/doesYour intervention
Precontemplation”I don’t have a problem” / minimizes consequencesPsychoeducation, no pressure, build rapport
Contemplation”Maybe I drink too much, but…” / ambivalentMotivational interviewing — explore pros/cons, discrepancy
Preparation”I’m ready to cut back, I just need a plan”Concrete action planning, skills prep
ActionActively reducing or abstainingRelapse prevention, coping skills, urge management
MaintenanceSustained change beyond 6 monthsPrevent complacency, manage long-term triggers

In the note, state the stage and justify it:

“Stage of change: contemplation. Client acknowledges work performance has declined (“my boss said something”) but attributes this to stress, not drinking. Ambivalent: lists 3 benefits of drinking (relaxation, social connection) vs. 2 concerns. Used double-sided reflection and decisional balance exercise.”

Craving and Trigger Documentation

CRAVINGS
Peak craving intensity this week: ___/10  When: _________________
Triggers identified: ________________________________
Coping response: ________________________________
Effectiveness (0-10): ___

Example:

“Cravings: peak 8/10 Thursday evening after performance review. Trigger: shame/anticipation of criticism. Used urge surfing — described craving as ‘a wave that came and went in about 20 minutes.’ Did not use. First time reported using a skill proactively.”

Relapse Documentation: Lapse vs. Relapse

A lapse is a single use episode. A relapse is a return to the previous use pattern. The distinction matters for treatment decisions and should be in the note.

LAPSE / RELAPSE (if applicable)
Type: □ Lapse (single episode)  □ Relapse (return to pattern)
Substance: ___________  Amount: ___________  Date: ___________
Triggers: ___________________________________________________
Client's response: □ Returned to plan  □ Demoralized  □ Ambivalent
Current stage of change post-relapse: _________________________
Safety: □ Overdose risk assessed  □ Tolerance decreased — documented
Plan revision: _____________________________________________

Example:

“Lapse: Saturday night — 4 beers at friend’s birthday after 23 days abstinent. Trigger: social pressure, hadn’t planned an exit. Client initiated contact Monday (not in crisis, wanted to ‘check in’). Reframed lapse as information rather than failure. Updated relapse prevention plan: identified 2 exit scripts for social events. Stage of change: remains in action — not demoralized, discussed what to do differently. Overdose risk assessed — tolerance likely reduced after 23-day abstinence; discussed risk of larger amounts. Will monitor.”

Safety Documentation

Safety in SUD counseling requires documenting three specific risks:

Withdrawal

WITHDRAWAL ASSESSMENT
Alcohol/benzo use: □ No  □ Yes
Physical symptoms: □ None reported  □ Tremor  □ Sweating  □ Nausea
                   □ Anxiety  □ Prior seizure history
Medical referral needed: □ No  □ Yes — [details]

Alcohol and benzodiazepine withdrawal can be fatal. Document it explicitly every session if the client is using heavily and considering stopping.

Overdose Risk

OVERDOSE RISK
Elevated risk factors: □ Recent abstinence / tolerance reduction
                       □ Polysubstance use
                       □ Use after release from treatment / incarceration
Naloxone: □ Discussed  □ Client has access  □ Not yet addressed

Suicidal Ideation

SUICIDAL IDEATION
SI assessed: □ None  □ Passive: _______  □ Active: ____________
Safety plan: □ In place  □ Updated  □ Not required

Substance Use Session Note Template

DATE: ____________  SESSION #: ___  DURATION: ___ min

USE SINCE LAST SESSION
Days used / days since last session: ___ / ___
Substances and amounts: _________________________________
Change from last session: □ More  □ Less  □ Same  □ Abstinent
Key context: ___________________________________________

STAGE OF CHANGE
Current stage: □ Precontemplation  □ Contemplation  □ Preparation
               □ Action  □ Maintenance
Justification (what the client said or did): _________________

CRAVINGS / TRIGGERS
Peak craving: ___/10  Trigger: ___________________________
Coping attempted: ________________  Effective: □ Yes □ No

LAPSE / RELAPSE (if applicable)
□ None  □ Lapse: _______  □ Relapse: ______
Triggers: ____________  Safety assessed: □ Yes

INTERVENTION
Approach: □ MI  □ CBT-SUD  □ Relapse Prevention  □ Harm Reduction
           □ Motivational Enhancement  □ Other: ___________
Specific technique: ____________________________________
Rationale (why this at this stage): _____________________
Client response: _______________________________________

FUNCTIONAL IMPACT
Work/school: ______  Relationships: ______  Health: ______  Legal: ______

CO-OCCURRING DISORDERS (if present)
Mood: ________  Anxiety: ________  Trauma: ________

MEDICATION-ASSISTED TREATMENT (if applicable)
Current MAT: ____________  Adherence: □ Yes  □ No  □ Not applicable
Coordination with prescriber: _________________________

SAFETY
Withdrawal risk: □ None  □ Assessed: ____________________
Overdose risk: □ Standard  □ Elevated — reason: __________
SI: □ None  □ Present: _________  Safety plan: □ In place

PLAN
Next session focus: ______________________________________
Between sessions: ________________________________________
Any referrals: ___________________________________________

Filled Example

Client: 34M, alcohol use disorder (moderate, DSM-5), co-occurring generalized anxiety. 6 sessions in. Court-mandated following DUI, also self-motivated. Stage of change at intake: contemplation.

Use since last session (7 days): Used 4 days — Mon, Wed, Fri, Sat. Down from 7/7 previous session. Amounts: 4-6 drinks on weekdays, 12+ on Saturday after argument with partner. First alcohol-free days in ~3 months.

Stage of change: Action — moved from contemplation to action this week. “I actually did not drink on Sunday and Monday. It was hard but I wanted to see if I could.” Used his emergency contact (brother) on Monday evening when craving hit. Actively implementing plan elements.

Cravings: Peak 8/10 Saturday evening. Trigger: conflict with partner (“she said I was selfish”) + being home alone. Craving management: called brother — helped short-term, still drank later that night. Urge surfing not attempted — “forgot about it in the moment.”

Intervention: MI + Relapse Prevention. Validated the 4 abstinent days — significant change. Explored Saturday episode: cognitive reconstruction of trigger (“she thinks I’m selfish, therefore I am, therefore what’s the point”). Practiced urge surfing in session. Cue card made for wallet: 3-step grounding before any drinking decision.

Functional: Work — functional (no incidents this week). Partner — conflict escalating, discussed couples therapy referral. Health — no withdrawal symptoms, confirms morning-only drinking pattern (not all-day).

Safety: Withdrawal — not assessed as medical emergency given current pattern (4-6 drinks/day, not morning-to-night). Will reassess if attempts full abstinence. Overdose: not applicable (alcohol). SI: assessed — none. Recent 4 abstinent days appear to improve mood, not worsen.

MAT: Offered discussion of naltrexone — interested, will bring up with PCP.

Plan: Continue RP. Practice urge surfing 1x before next session (non-crisis moment). Client to track triggers in phone notes. Referral letter prepared for PCP re: naltrexone consult.

Documenting Co-Occurring Disorders

SUD rarely presents alone. When co-occurring disorders are present:

  • Document which is primary (or if they’re bidirectional) — this affects treatment sequencing
  • Note how they interact — anxiety often precedes use (“drinks to calm down”); depression often follows (“uses to cope, feels worse after”)
  • Track both in parallel — depression scores alongside use days gives a clearer picture than either alone

“PHQ-9: 12 (moderate). Depression symptoms appear to follow heavy use days (Mon, Wed after weekend use). No depression reported on abstinent days this week. Hypothesis: maintaining abstinence may reduce depressive symptoms without separate treatment — will monitor over 4 weeks before adding antidepressant discussion.”

TheraMemory’s session chronology makes it straightforward to track abstinent days and use trends across sessions. Client context — including substance, stage of change, and relapse prevention plan — stored in «Important Information» and visible before each session.

See Also

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