Substance Use/Addiction Discharge Summary Template
Use this basic template when documenting discharge for clients who received treatment related to substance use, cravings, relapse prevention, recovery support, or functional impairment.
Clinical Pearl: Discharge can strengthen recovery by reviewing triggers, supports, coping strategies, and realistic relapse prevention steps.
Reason for Treatment
Client participated in treatment to address substance use related concerns, including cravings, relapse risk, coping patterns, triggers, consequences of use, motivation for change, or recovery support needs.
Course of Treatment
Treatment focused on psychoeducation, motivational interviewing, coping skills, relapse prevention, trigger identification, harm reduction or abstinence based planning as appropriate, and strengthening support systems.
Progress Made
Client demonstrated progress in identifying triggers, increasing insight into substance use patterns, developing coping strategies, strengthening motivation, and identifying supports for recovery.
Continued Care Recommendations
Client may continue to benefit from relapse prevention planning, recovery supports, accountability, coping skill practice, and ongoing monitoring of cravings, triggers, and high risk situations.
Discharge Plan
Client is discharged at this time with recommendation to continue using recovery supports and seek additional care if cravings, relapse risk, or substance use concerns increase.