Substance Use Disorder Progress Note Template for Addiction Counselors

A complete progress note template for SUD and addiction counselors. Covers DAP and SOAP formats for individual and group sessions, MAT follow-ups, relapse indicators, and 42 CFR Part 2 compliance.

Substance use disorder documentation carries obligations that most other mental health specialties do not face. Your notes must satisfy clinical standards, satisfy third-party payers, and comply with 42 CFR Part 2, the federal confidentiality regulation that adds an extra layer of protection to records held by any program that receives federal funding and identifies itself as specializing in substance use disorder treatment.

That creates a documentation challenge that is both mundane and high-stakes. The note has to document what happened in the session. It also has to avoid becoming evidence that could follow your client through a background check, a custody hearing, or a disability determination if records are ever improperly disclosed.

This template gives you a complete, fillable structure for both individual and group sessions, in both DAP and SOAP formats. A worked example using fictional client data follows each template. Compliance notes are woven in throughout rather than saved for a separate section, because in SUD documentation, compliance and clinical content cannot really be separated.

Why SUD Progress Notes Have Unique Requirements

Standard therapy documentation rules apply here: notes must support medical necessity, reflect the clinician's professional judgment, and document progress toward treatment goals. But several factors make SUD documentation its own discipline.

42 CFR Part 2 prohibits disclosure of patient records from federally assisted SUD programs without explicit written patient consent for each disclosure (with narrow exceptions for emergencies, audits, and court orders). Unlike HIPAA, which allows general treatment-payment-operations disclosures, Part 2 requires that the patient's identity as someone receiving SUD treatment not be revealed without consent. This affects what you can write in shared records and how you respond to subpoenas.

ASAM Criteria (the American Society of Addiction Medicine Patient Placement Criteria) provides the clinical framework most insurers use to authorize level of care. Your notes need to reflect the six ASAM dimensions: acute intoxication and withdrawal potential, biomedical conditions, emotional/behavioral conditions, readiness to change, relapse potential, and recovery environment. You do not need to list them by name in every note, but your clinical content should address these domains.

Medication-assisted treatment adds a documentation layer when clients are prescribed buprenorphine, methadone, or naltrexone. You are not the prescriber, but your notes should reflect treatment engagement, adherence, reported side effects, and the clinical picture that informs the prescribing team's decisions.

Group session confidentiality in Part 2 settings is stricter than standard group therapy rules. The group note should not name other members or describe their disclosures. Each member's note documents only that member's participation and response.

Individual Session Templates

DAP Format: Individual SUD Progress Note

SESSION HEADER

Client identifier (use initials or assigned ID per your agency policy):
Date of service:
Session number:
Session type: Individual
Modality: In-person / Telehealth (video) / Telehealth (phone)
Session duration:
CPT code: 90837 / 90834 / 90832 / H0004 / other:
Clinician name and credentials:
Supervising clinician (if applicable):

D — DATA

Substance Use Report:

Days of use since last session (substance, amount, route if clinically relevant):
Last use date:
Client's self-assessment of use pattern (stable / increased / decreased / abstinent):
Reported triggers or high-risk situations encountered:
Use of any substances not on the treatment plan (include OTC, marijuana if in non-legal jurisdiction, etc.):
Drug screen results (if obtained this session):

MAT Status (if applicable):

Current medication (buprenorphine / methadone / naltrexone / other):
Adherence reported (taking as prescribed / missed doses / use concerns):
Reported side effects or medication concerns:
Prescriber contact or coordination this period:

Withdrawal and Medical Observations:

Current withdrawal symptoms reported or observed:
CIWA-Ar or COWS score if assessed:
Medical concerns reported:

Mental Status and Presentation:

Appearance (grooming, dress, signs of intoxication or withdrawal):
Affect and mood (stated and observed):
Speech (rate, volume, clarity):
Thought process (logical / circumstantial / tangential / disorganized):
Cognition (alert and oriented / grossly impaired):
Engagement level (cooperative / guarded / ambivalent / avoidant):

Session Content:

Presenting concerns client raised:
Topics covered (e.g., relapse prevention, coping skills, family impact, triggers, grief, housing):
Interventions used (name the approach: motivational interviewing, CBT, 12-step facilitation, contingency management, relapse prevention planning, etc.):
Client's in-session response to interventions:
Homework or between-session task reviewed from previous session (completed / partial / not completed; reason if not):

Relapse Indicators Assessed:

Craving intensity (0-10 scale):
High-risk situations anticipated this week:
Protective factors present (sponsor contact, sober supports, meeting attendance, stable housing, employment):
Early warning signs identified by client:

Risk Screening:

Suicidal ideation: present / absent. If present, describe ideation, intent, plan, means, and immediate action taken:
Homicidal ideation: present / absent:
Overdose risk (recent use of opioids / fentanyl exposure risk, naloxone availability):
Domestic violence or safety concerns:

A — ASSESSMENT

Clinical impression and interpretation of the above data:
Diagnostic formulation (DSM-5-TR diagnosis with ICD-10-CM code; note severity: mild / moderate / severe):
ASAM dimension summary (address any dimensions showing change or clinical concern):
- Dimension 1 (Intoxication/Withdrawal):
- Dimension 2 (Biomedical):
- Dimension 3 (Emotional/Behavioral):
- Dimension 4 (Readiness to Change):
- Dimension 5 (Relapse Potential):
- Dimension 6 (Recovery Environment):
Progress toward treatment goals (address each active goal):
- Goal 1:
- Goal 2:
- Goal 3:
Current level of care appropriateness (outpatient / IOP / PHP / residential — state whether current level remains appropriate or whether reassessment is indicated):
Stage of change assessment (precontemplation / contemplation / preparation / action / maintenance):
Strengths and protective factors observed:
Risk summary (low / moderate / high for relapse; low / moderate / high for self-harm; rationale):

P — PLAN

Between-session tasks assigned:
Crisis plan reviewed: yes / no. If yes, describe any updates:
Naloxone plan (client has naloxone / referral given / declined / not indicated):
Referrals made this session:
MAT prescriber coordination needed: yes / no. If yes, describe:
Next session focus:
Schedule: next appointment date and time, session type, duration:
Any change to treatment plan: yes / no. If yes, describe and note that updated treatment plan will be completed:

CLINICIAN SIGNATURE

Name and credentials:
License number:
Date and time note completed:
Signature:

SOAP Format: Individual SUD Progress Note

If your agency uses SOAP format or you work in a setting with medical team integration, this structure separates subjective and objective information.

SESSION HEADER (same fields as DAP header above)

S — SUBJECTIVE

What the client reported, in their own words where possible:

Substance use since last session (client self-report):
Direct quotes that convey clinical significance (e.g., "I almost used Friday but called my sponsor"):
Current symptoms reported (craving, anxiety, depression, insomnia, physical complaints):
Stressors reported:
Response to previous session's homework or recommendations:
MAT adherence as reported by client:

O — OBJECTIVE

What the clinician observed or measured:

Appearance (objective description — do not interpret here):
Vital signs if obtained:
Drug screen result if obtained (substance, result — positive / negative / dilute / refused):
CIWA-Ar or COWS score if obtained:
Standardized screening scores if administered (AUDIT-C, DAST-10, PHQ-9, GAD-7, PCL-5 — report score and threshold):
Behavioral observations (engagement, affect, eye contact, psychomotor activity):
Records received from prescriber or other providers:

A — ASSESSMENT

(Same structure as DAP Assessment above)

P — PLAN

(Same structure as DAP Plan above)

Group Session Template

Group sessions in SUD treatment require separate documentation from individual sessions. Under 42 CFR Part 2, each group member's participation must be documented in a way that does not expose other members' identities or disclosures.

GROUP SESSION HEADER

Client identifier:
Date of service:
Group name or type (e.g., Early Recovery Skills, Relapse Prevention, Process Group, Psychoeducation):
Group session number (for this client):
Group session duration:
Number of members present (do not list names):
Facilitator(s) name and credentials:
CPT code: H0005 / 90853 / other:

DATA / SUBJECTIVE

Client's attendance and punctuality:
Client's level of participation (active / passive / resistant / absent for portion):
Content this member contributed (without naming other members or describing their disclosures):
Themes the group addressed today (describe topically, e.g., "The group explored high-risk situations associated with social events"):
Specific skill or topic practiced in group (name it):
This member's response to the group content:
Substance use report (if disclosed in group by this member):
Any between-session homework reviewed in group for this member:

ASSESSMENT

Clinical impression of this member's participation and progress:
Change in motivation, insight, or skill since last group session:
Group cohesion and therapeutic alliance observation for this member:
Progress toward treatment goals that are addressed by group participation:
Risk assessment (suicidal ideation, relapse risk — document only for this member):

PLAN

Between-session task assigned in group:
Referral to individual session if clinical concern arose:
Next group session scheduled:
Any coordination with individual counselor needed:

CLINICIAN SIGNATURE (same as individual template)

Worked Example: Individual DAP Note

The following uses fictional client data. All names, identifiers, and clinical details are invented.

CLIENT: R.M. | DATE: 2026-04-10 | SESSION: 14 | CPT: 90837

D — Data

R.M. arrived on time and appeared alert. Grooming was appropriate. No observable signs of intoxication or withdrawal. He reported two days of alcohol use in the past two weeks, both on weekends: one beer at a family gathering on April 4th and three beers at a friend's house on April 8th. He identified the second occasion as a higher-risk situation because "I wasn't planning to drink, but everyone else was and it happened without thinking." He denied use of any other substances. Drug screen (urine) was obtained; result was negative for all panels.

R.M. is currently prescribed naltrexone 50 mg daily and reports taking it consistently, with no side effects. He saw his prescribing physician on April 7th and plans to continue current dosing.

Mood reported as "mostly okay, a little frustrated with myself." Affect was mildly dysphoric with some affect brightening when discussing his recent return to the gym. Speech was normal rate and volume. Thought process was logical and goal-directed.

Session focused on the April 8th lapse and its functional antecedents. Clinician used motivational interviewing to explore ambivalence: R.M. acknowledged the lapse felt different from earlier heavy-use episodes but was concerned about the "without thinking" quality of the decision. Cognitive-behavioral relapse prevention framework was used to map the chain of events: attending a social event without a pre-planned exit strategy, peer pressure response, and the absence of a coping phrase he had been practicing. R.M. completed his between-session thought record; reviewed together and provided specific positive reinforcement. Craving intensity this week rated 3/10.

Risk: R.M. denies suicidal ideation, self-harm, or homicidal ideation. Overdose risk low given naltrexone adherence and abstinence from opioids. Naloxone on hand at home. No domestic violence or safety concerns.

A — Assessment

R.M. presents with Alcohol Use Disorder, moderate (F10.20), in early remission. The April 8th lapse represents a slip rather than a full relapse: two drinks consumed, not followed by sustained heavy use, and the client voluntarily disclosed without minimization. Ambivalence about social drinking contexts remains a clinical target. Motivation for change is high (action stage); craving intensity has decreased significantly from session 1 (rated 8/10) to current 3/10.

ASAM Dimension 5 (Relapse Potential): Moderate. Social environments with alcohol present remain high-risk. Client lacks consistent exit strategy for unplanned exposure. Dimension 4 (Readiness to Change): Action stage maintained. Dimension 6 (Recovery Environment): Largely supportive but social circle includes heavy drinkers.

Goal 1 (Achieve and maintain abstinence from alcohol): Partial progress. Two-drink lapse this period; no heavy use episode. Goal 2 (Develop coping strategies for high-risk social situations): Moderate progress. Identified the antecedent chain; has not yet practiced exit strategy in real situations. Goal 3 (Maintain naltrexone adherence): Achieved.

Level of care: Outpatient weekly individual counseling remains appropriate. No indication for stepped-up care.

Risk: Low for self-harm. Moderate for relapse in unplanned social exposure without coping strategy in place. Protective factors: naltrexone adherence, gym attendance, engaged in treatment, voluntary disclosure of lapse.

P — Plan

Between-session task: Identify two upcoming social events with potential alcohol exposure and write a brief exit strategy for each (what to say, when to leave, who to text).
Practice the pre-planned coping phrase three times before the next high-risk social event.
Discuss exit strategies at next session. Review thought record.
Crisis plan: reviewed. No updates needed. R.M. verbalized his crisis plan and counselor contact number.
Naloxone: confirmed present at home.
No changes to treatment plan.
Next session: April 17, 2026, 60-minute individual, in-person.

J. Rivera, LCADC | License: LCADC-12345 | Note completed: April 10, 2026, 3:45 PM

42 CFR Part 2 Documentation Considerations

Every note you write in a federally assisted SUD program exists within the Part 2 framework. A few documentation practices matter specifically.

Do not use the term "substance abuse" in note headers or identifiers that could appear in a general medical record. The safer approach is to use a client identifier (initials or assigned number) and keep notes in a segregated record system.

Group notes must not identify other group members. Never write "Client reported that another group member relapsed and it triggered her." Write instead: "Client reported that a peer's disclosure in group today triggered craving thoughts. Explored personal response and applied relapse prevention coping strategy."

Coordination of care notes require separate consent. If you send information to a primary care physician or another mental health provider, the written consent must specifically authorize disclosure to that recipient and describe what information will be shared. The general ROI your client signed at intake is not sufficient under Part 2 unless it was drafted to meet Part 2's specific requirements.

MAT-related communication is particularly sensitive. Even confirming that a client is enrolled in a MAT program to another provider requires Part 2-compliant consent. Document any such communication, including the consent form used.

Audit readiness: All notes should be signed and timed on the day of service or as close to it as possible. Late entries should be labeled clearly as late entries with the reason documented.

Common Documentation Mistakes in SUD Settings

Documenting use without clinical context. "Client used heroin three times this week" is a data point. "Client used heroin three times this week in the context of conflict with his partner and inadequate activation of his coping plan, suggesting that interpersonal stressors remain a high-risk trigger not yet addressed in treatment" is a clinical note.

Identical notes across sessions. Auditors flag notes that read the same session after session. Even when progress is gradual, something changes: craving intensity, a new stressor, a specific intervention tried and how the client responded.

Omitting relapse risk assessment. Every SUD note should include some documentation of relapse risk, even when the client is doing well. "No current relapse indicators. Client maintains recovery environment supports and reports craving at 1/10" takes one sentence and protects you clinically and legally.

Missing the ASAM lens. If your notes address symptom management but not placement criteria, your documentation may not support continued authorization at your current level of care. A note that says "client is doing better" without addressing the six ASAM dimensions cannot justify continued weekly outpatient sessions to a utilization reviewer.

Narrative that identifies other group members. Even a well-intentioned note like "Client stated she was glad her friend in group shared about her relapse because it helped her stay honest" exposes another member's identity and relapse status. This is a Part 2 violation.

Not documenting naloxone status. For clients with opioid use disorder or who use fentanyl-contaminated substances, naloxone availability is a safety-relevant clinical fact. Document it.

Pre-Submission Checklist

Before signing any SUD progress note, verify the following:

Clinical Completeness

Substance use status documented with specific detail (days, amount, or confirmed abstinence)
Drug screen result recorded if obtained
Relapse risk assessed with supporting rationale
Interventions named (not just "therapy provided")
Progress toward each active treatment goal addressed
Risk screening completed and documented (SI, HI, overdose risk)

MAT Documentation (if applicable)

Current medication and dose noted
Adherence status documented
Prescriber coordination noted if any occurred

42 CFR Part 2 Compliance

Note does not identify other group members (for group notes)
Any coordination of care is covered by a valid Part 2-compliant consent
Note is in a segregated SUD record if required by your program

Administrative

Note signed and timed on the date of service (or labeled as late entry if not)
CPT code matches session type and duration
Client identifier used correctly per agency policy

If you write SUD notes at high volume, tools like NotuDocs allow you to build a SUD-specific progress note template with all required fields, so your documentation structure stays consistent across every client and session type. The template-first approach means you control the format; the tool fills the structure from your session notes rather than generating clinical content you have not verified.

For deeper guidance on specific areas of SUD documentation, see How to Document Substance Abuse and Addiction Counseling Sessions, 42 CFR Part 2 and AI Documentation for Substance Use Counselors, and How to Document Intensive Outpatient Program Sessions.