At SUD RECOVERY CENTERS, all clients are provided a psychiatric diagnostic assessment by either a Psychiatrist, an Advanced Practice Nurse Prescriber with Psychiatric Specialty, a Physician’s Assistant with Psychiatric Specialty, a Master’s Level Psychotherapist or a Clinical Psychologist with a Ph.D.

Assessment – Definition

According to the National Institutes of Health (NIH):

“Assessment is a process for defining the nature of [the SUD] problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.”

Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 51.) Chapter 4: Screening and Assessment. Accessed 4.26.2021 from:

“A thorough substance use assessment includes a detailed inventory of the type, amount, frequency, and consequences of the patient’s substance use, their perception of their use and readiness to change, an assessment of co-occurring psychiatric disorders, a medical history, physical examination and laboratory tests, the presence of substance use disorder in the patient’s family, and review of social factors that may contribute to substance use or facilitate treatment.”

Karen L Dugosh, PhD and John S Cacciola, PhD, Clinical assessment of substance use disorders, Publisher Wolters Kluwer.  Accessed 4.26.2021 from:

SAMHSA advises: “Use SUD assessment results to tailor treatment and services to fit individual needs. A SUD assessment can provide a clinical diagnosis and recommendations for the intensity and setting of treatment needed (outpatient, intensive outpatient, or residential) and supportive services. The SUD assessment may also identify co-occurring mental disorders and areas of life functioning affected, such as family relationships, employment, housing, or criminal justice involvement. Each of these areas may require a specific service or referrals to other agencies.”

SAMHSA, Understanding Screening and Assessment of Substance Use Disorders.  Accessed 4.26.2021 from:

Assessment – Wisconsin Law – DHS 83

The assessment is meant to comply with provisions of Wisconsin law under which SUD RECOVERY CENTERS are required to conduct both a psychiatric and a physical health an assessment of each client prior to admission, to wit:

[Note: All text is from the original Code.  Highlighting in yellow has been supplied.]

DHS 83.35   Assessment, individual service plan and evaluations.

    1. Assessment.

(a) Scope. The CBRF [i.e., SUD Recovery Centers] shall assess each resident’s needs, abilities, and physical and mental condition before admitting the person to the CBRF…The assessment shall include all areas listed under par. (c)

(b) Information gathering. The CBRF shall base the assessment on the current diagnostic, medical and social history obtained from the person’s health care providers, case manager and other service providers. Other service providers may include a psychiatrist, psychologist, licensed therapist, counselor, occupational therapist, physical therapist, pharmacist or registered nurse. The administrator or designee shall hold a face-to-face interview with the person and the person’s legal representative, if any, and family members, as appropriate, to determine what the person views as his or her needs, abilities, interests, and expectations.

(c) Areas of assessment. The assessment, at a minimum, shall include all of the following areas applicable to the resident:

    1. Physical health, including identification of chronic, short-term and recurring illnesses, oral health, physical disabilities, mobility status and the need for any restorative or rehabilitative care.
    2. Medications the resident takes and the resident’s ability to control and self-administer medications.
    3. Presence and intensity of pain.
    4. Nursing procedures the resident needs and the number of hours per week of nursing care the resident needs.
    5. Mental and emotional health, including the resident’s self-concept, motivation and attitudes, symptoms of mental illness and participation in treatment and programming.
    6. Behavior patterns that are or may be harmful to the resident or other persons, including destruction of property.
    7. Risks, including, choking, falling, and elopement.
    8. Capacity for self-care, including the need for any personal care services, adaptive equipment or training.
    9. Capacity for self-direction, including the ability to make decisions, to act independently and to make wants or needs known.
    10. Social participation, including interpersonal relationships, communication skills, leisure time activities, family and community contacts and vocational needs.

Assessment – Wisconsin Law – DHS 75.03

The assessment is meant to comply with provisions of Wisconsin law under which SUD RECOVERY CENTERS are required to conduct both a psychiatric and a physical health an assessment of each client prior to admission, to wit:

[Note: All text is from the original Code.  Highlighting in yellow has been supplied.]


(a) Staff of a service [i.e., SUD Recovery Centers] shall assess each patient through screening interviews, data obtained during intake, counselor observation and talking with people who know the patient. Information for the assessment shall include all of the following:

        1. The substance abuse counselor’s evaluation of the patient and documentation of psychological, social and physiological signs and symptoms of substance abuse and dependence, mental health disorders and trauma, based on criteria in DSM-IV.
        2. The summarized results of all psychometric, cognitive, vocational and physical examinations taken for, or as a result of, the patient’s enrollment into treatment.

(b) The counselor’s recommendations for treatment shall be included in a written case history that includes a summary of the assessment information leading to the conclusions and outcomes determined from the counselor’s evaluation of the patient’s problems and needs.

(c) If a counselor identifies symptoms of a mental health disorder and trauma in the assessment process, the service shall refer the individual for a mental health assessment conducted by a mental health professional.

(d) If a counselor identifies symptoms of physical health problems in the assessment process, the service shall refer the individual for a physical health assessment conducted by medical personnel.

(e) Initial assessment shall be conducted for treatment planning. The service shall implement an ongoing process of assessment to ensure that the patient’s treatment plan is modified if the need arises as determined through a staffing at least every 30 days.

Assessment – Federal Law

The assessment is meant to comply with provisions of federal law under which SUD RECOVERY CENTERS are required to conduct both a psychiatric and a physical health an assessment of each client prior to admission, to wit:

42 CFR 8.12(f) Required Services.  Under federal law, the following are “required services” that must be provided by an Opioid Treatment Program (OTP).

OTPs must provide adequate medical, counseling, vocational, educational, and other assessment and treatment services. (Emphasis added.) Any assessments or treatments not directly provided at the facility must be assured via a formal documented agreement with the appropriate community providers.

Assessment begins during program admission and continues throughout treatment. Its purpose is to address the whole health and well-being of the patient (emphasis added). Assessment begins with a personal substance use history, physical examination, laboratory evaluation, and determination of disease morbidity.

All individuals who meet OTP admission criteria must receive a complete, fully documented physical evaluation (emphasis added) prior to admission to the OTP. The purpose of the initial medical evaluation is to confirm the diagnosis of opioid use disorder and identify co-occurring medical and psychiatric conditions that may make medication-assisted treatment unsafe, limit its effectiveness, influence the selection of pharmacotherapy, or require prompt medical attention.

Screening should be conducted for common co-occurring conditions even if the patient has no personal history of them. Screening should establish the risk of undiagnosed conditions such as Hepatitis C, the human immunodeficiency virus (HIV), sexually transmitted infections (STIs), cardio-pulmonary disease, and sleep apnea in order to determine what further diagnostic testing such as laboratory studies, a cardiogram, and others are needed.

Initial toxicology tests are a part of the admission process. At a minimum, admission samples are tested for opioids, methadone, buprenorphine, amphetamines, cocaine, marijuana, and benzodiazepines. If there is a history of prescription opioid analgesic abuse, an expanded toxicology panel that includes these opioids should be administered.

Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP (SMA). Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.  Accessed May 3, 2021 from Federal Guidelines for Opioid Treatment Programs (