Substance Use/Addiction Client Presentation Statements

Use these statements when documenting how substance use or addiction related concerns may present in session, assessment, treatment planning, or progress notes. Language should remain objective, nonjudgmental, and connected to symptoms, functioning, safety, motivation, and recovery needs.

Substance Use Patterns & Loss of Control

• Client presents with difficulty reducing, controlling, or stopping substance use despite expressed desire to make changes.
• Patient reports repeated unsuccessful attempts to decrease or discontinue use.
• Client describes difficulty maintaining intended limits around substance use.
• Patient reports increased time, attention, or energy spent obtaining, using, recovering from, or thinking about substance use.
• Client presents with concern that substance use feels harder to control than intended.

Consequences & Functional Impairment

• Client reports substance use has contributed to impairment in relationships, work, school, parenting, finances, health, or daily responsibilities.
• Patient presents with continued substance use despite awareness of negative consequences.
• Client identifies risky situations or behaviors associated with substance use.
• Patient reports decline in functioning related to ongoing substance use patterns.
• Client describes difficulty meeting responsibilities due to effects of substance use, recovery from use, or related emotional distress.

Cravings, Triggers & Emotional Coping

• Client presents with recurrent cravings or strong urges to use substances.
• Patient reports difficulty identifying or managing internal or external triggers.
• Client describes using substances to cope with stress, emotional discomfort, anxiety, sadness, anger, trauma reminders, or relational distress.
• Patient reports increased vulnerability to use during periods of emotional dysregulation or high stress.
• Client identifies cravings as a barrier to maintaining recovery goals or intended changes.

Motivation, Ambivalence & Readiness

• Client presents with ambivalence about changing substance use patterns.
• Patient reports both reasons for change and perceived benefits of continued use.
• Client expresses uncertainty about readiness, confidence, or ability to reduce or stop use.
• Patient identifies barriers to change, including stress, social environment, cravings, limited support, or fear of discomfort.
• Client demonstrates need for continued exploration of motivation, values, and realistic recovery goals.

Recovery & Relapse Vulnerability

• Client presents with difficulty maintaining abstinence, reduced use, or recovery goals over time.
• Patient reports recurrence of substance use following a period of progress or stability.
• Client has difficulty recognizing early warning signs of recurrence or relapse vulnerability.
• Patient reports increased risk of use during stress, conflict, environmental exposure, isolation, or reduced support.
• Client would benefit from relapse prevention planning, coping skills, and increased support.

Co-Occurring Symptoms & Safety

• Client presents with mental health symptoms occurring alongside substance use concerns.
• Patient reports substance use may worsen or temporarily mask emotional, behavioral, or psychological symptoms.
• Client presents with concerns related to intoxication, withdrawal, overdose risk, impaired judgment, or other substance related safety concerns.
• Patient may benefit from coordination with medical, psychiatric, behavioral health, or substance use treatment supports.
• Client demonstrates need for continued monitoring of safety, risk, symptoms, and level-of-care needs.