A DAP outline for substance use sessions
Client: [identifier your setting uses] Date of service: [date] Start and end time: [00:00 to 00:00] Session type: [individual / couple / family / group; in person or telehealth] Telehealth (optional): [client's location this session; video or audio only] Service code: [if you bill] Clinician: [name, credentials] Treatment-plan goal addressed: [the client's goal, in their words if possible] D (Data) - Use since last session, by substance: [days used, amount per day, form or route, last use] - What the client reported (cravings, triggers, consequences, what went well): [ ] - Withdrawal symptoms or medical concerns reported: [ ] - What you observed (presentation, signs of intoxication or withdrawal): [ ] - Ratings and measures (for example importance and confidence, 0 to 10): [ ] - Interventions used in session: [ ] - Risk: thoughts of suicide, self-harm or harm to others; overdose risk; driving after use: [ ] A (Assessment) - Your clinical interpretation: [ ] - Progress toward the client's goal, with the numbers: [ ] - Response to today's interventions: [ ] - Risk level and reasoning: [ ] P (Plan) - What the client agreed to try: [ ] - Next session focus and interventions: [ ] - Medical referral or coordination of care (consent as your setting and the law require): [ ] - Next appointment and frequency: [ ] Signature, credentials, date: [ ]
What to record when substance use is a focus
- Amounts, not adjectives. "Drinking heavily" tells the next clinician little. Record the days used and the amount per day. For alcohol, use standard drinks per drinking day. In the US, a standard drink is about 14 grams of pure alcohol: 12 ounces of regular beer (about 5% alcohol), 5 ounces of wine (about 12%) or 1.5 ounces of spirits (about 40%). Going through the past week day by day on a calendar helps pin the numbers down.
- Form and route for other substances. For cannabis, record the form (smoked, vaped or eaten), how often and how much in the client's terms, such as the milligrams on an edible's label. For other drugs, record the substance as the client knows it, the route and the last use.
- The client's own goal. Stopping, cutting down and using more safely are different goals. Record the one the client has chosen, in their words where possible, or that they have not decided yet.
- Withdrawal and medical concerns, in proportion to the use. Stopping alcohol after regular heavy use, or benzodiazepines after regular use (even as prescribed), can bring medically serious withdrawal, so record what you asked and any medical referral. Cannabis withdrawal (irritability, poor sleep, low appetite) is uncomfortable but not usually dangerous. After a period without opioids, tolerance drops, so a return to use carries a higher overdose risk. For light use, a short line that no withdrawal symptoms were reported is enough.
- Motivational interviewing, named accurately. Record the skills you used (open questions, affirmations, reflections, importance and confidence rulers) and what the client said for and against change. Ruler scores give you a number to track across sessions.
- Harm reduction, as specific steps. Record what was discussed and what the client agreed to, for example naloxone at home, not using alone or not driving after use.
- Consent and confidentiality. When you coordinate with a prescriber or another provider, record what you shared, with whom, and that the client's written consent is on file. Records of federally assisted substance use disorder programs carry extra federal confidentiality rules (42 CFR Part 2), including limits on sharing them without the client's written consent. Whether your practice counts as such a program, or holds records received from one, depends on your setting, so check with your organization, privacy officer or attorney rather than assuming either way. State law may add its own rules.
Language
Clients and other providers may read the note, so describe rather than label.
| Instead of | Write |
|---|---|
| Substance abuse, abuser, addict, alcoholic | Substance use; a client who uses alcohol; a person with an opioid use disorder (when diagnosed) |
| Clean or dirty (test results) | Tested negative or tested positive |
| In denial, resistant | What the client said, for example "says evening use isn't a problem" |
| Noncompliant | What happened, for example "missed two doses this week" |
Three filled examples
All examples on this page are fictional composites. They do not describe real clients.
Each real note would also carry the date, start and end time, session type, who attended and the clinician's signature; they are left out here to keep the examples short.
1. Alcohol, cutting down, in person, 50 minutes.
An adult client in their 40s, session 3. Treatment goal 1 (the client's goal): drink on no more than three days a week, and no more than two standard drinks on those days.
D: Client reports drinking on 5 of the past 7 days, 4 to 5 standard drinks (12-ounce beers, about 5%) per drinking day, mostly in the hour after work: about 20 to 25 standard drinks this week. At intake: daily, 6 to 8 standard drinks (42 to 56 a week). Reviewed the week day by day on a calendar. Had two alcohol-free days, the first in months; "slept worse but felt clearer." Said they want to be "sharp for my kids in the morning." Reports no shakiness, sweating, racing heart or morning drinking. Denies driving after drinking. Alert, speech clear, no signs of intoxication. Importance and confidence rulers (0 to 10): importance of cutting down 8, confidence 5 (3 last session). Motivational interviewing: open questions and reflections on the alcohol-free days; asked what moved confidence from 3 to 5 (client: "seeing I could do it twice"). Denies thoughts of suicide, self-harm or harm to others. A: Partial progress toward goal 1: drinking days down from 7 to 5 and the weekly total down by about half. Change talk centers on their children and on the two alcohol-free days. The hour after work is the main high-risk time. Poorer sleep on alcohol-free days may be mild withdrawal after daily heavy drinking; no other withdrawal signs reported, and this needs checking at each session as drinking falls. Risk judged low: denies suicidal ideation and driving after drinking. P: Client's plan: gym after work on Tuesday and Thursday, no alcohol in the house on weeknights, count drinks in a phone note. Reviewed withdrawal signs that need prompt medical care (shaking, sweating, confusion, seizures, seeing or hearing things that are not there); client agreed to seek care if any appear and to talk with their primary care provider before stopping completely. Visit already booked for next month. Next session in one week.
Why it works: amounts are in standard drinks per drinking day with a weekly total, the goal is the client's, motivational interviewing is recorded as specific skills with ruler scores, and the withdrawal and medical language matches daily heavy drinking at intake.
2. Cannabis, undecided about change, telehealth, 50 minutes.
An adult client in their 20s, session 2. Treatment goal 1 (the client's goal): no missed or late work shifts (one missed and two late last month).
D: Video session; client confirmed they were at home. Client reports vaping THC every evening, about 6 to 8 puffs, "to sleep," and eating a 10 mg THC edible on two afternoons before work this week. Late for one shift, after an afternoon edible; no missed shifts. Says evening use "isn't a problem" and is "the only thing that helps me sleep"; slept about 3 hours on the one night without cannabis last month. Alert and engaged; gave shorter answers when evening use came up. Importance and confidence rulers (0 to 10): stopping afternoon use, importance 6 and confidence 7; cutting evening use, importance 2. Motivational interviewing: open questions, double-sided reflections and, with permission, information on cannabis and sleep. Client agreed not to drive after using. Denies thoughts of suicide, self-harm or harm to others. A: Partial progress toward goal 1: no missed shifts this week, one late arrival. Client links afternoon use to lateness and shows change talk about it; evening use is not something they want to change now, and the plan follows the client's priority. Poor sleep without cannabis may reflect withdrawal after nightly use, an underlying sleep problem or both. Risk judged low: denies suicidal ideation; agreed not to drive after use. P: Client's plan: no edibles on workdays this week. Keep a daily log of cannabis use (form, amount, time) and sleep. Next session in one week: review the log and begin sleep work, starting with a consistent wake time.
Why it works: ambivalence is recorded as what the client said and rated, not as "resistance", the work follows the use the client wants to change, and the note keeps the explanation for poor sleep open rather than settling it.
3. Opioids, alongside buprenorphine treatment, in person, 50 minutes.
An adult client in their 30s, session 7, who receives buprenorphine from a separate prescriber. Treatment goal 1 (the client's goal): no use of non-prescribed opioids, with buprenorphine taken as prescribed.
D: Client raised at the start of session that they used once on Saturday: snorted part of a pill sold as oxycodone, bought from a friend, after an argument with their partner, while home alone. No alcohol or other drugs used with it. No other non-prescribed opioid use in the 5 weeks before. Taking buprenorphine daily as prescribed. Cravings (0 to 10): 6 on Saturday, 2 since. Says the use was "to shut my brain off," not to die. Denies thoughts of suicide, self-harm or harm to others; no past suicide attempts or overdoses; no firearms or stockpiled medication at home. Calm and engaged; tearful when describing the argument. Affirmed the client for raising the use. Relapse prevention: mapped the lead-up to Saturday (argument, alone, pills offered by a friend) and planned responses to the next argument (leave the room, walk, call their sister). Harm reduction: discussed that pills bought outside a pharmacy may contain fentanyl. Client has naloxone at home; their partner knows where it is, how to use it and to call 911. Client agreed not to use alone. A: Progress toward goal 1: one day of non-prescribed use in the past 6 weeks, with buprenorphine taken daily. The use followed conflict at home while alone, a high-risk situation the plan now addresses. Prompt disclosure and active planning are strengths. Overdose risk is raised by this week's use of a pill of unknown content; protective factors are ongoing buprenorphine treatment, naloxone at home and the agreement not to use alone. Judged low acute suicide risk: risk factors are the opioid use and the conflict at home, but denies suicidal ideation, describes the use as escape rather than self-harm, no past attempts, no access to firearms; partner support and engagement in treatment are protective factors. P: Client will tell their prescriber at Thursday's appointment; with written consent on file, counselor will confirm with the prescriber's office afterwards. Practice the plan for the next argument. Client has the 988 Suicide and Crisis Lifeline number for a crisis between sessions. Next session in one week, sooner if cravings rise.
Why it works: it records the use specifically and without judgment, names the relapse prevention and harm reduction steps, separates overdose risk from suicide risk with reasoning for each, and records consent before any coordination.
Common mistakes
- Vague amounts. "Drinking a lot" or "some cannabis use" cannot be compared from week to week. Record days used and the amount per day.
- Labels instead of behavior. "In denial" or "resistant" gives your conclusion, not what happened. Record what the client said and how they rated it.
- An Assessment that repeats the numbers. The Data has the amounts. The Assessment says what the change means for the client's goal and for risk.
- Your goal instead of the client's. Record the goal the client chose. If your program requires a particular goal, record both and how you discussed them.
- Overdose or withdrawal risk left out. After opioid use or heavy daily drinking, record what you asked, what you found and what was agreed.
- Coordination without consent recorded. Before noting a call to a prescriber or family member, record what was shared and the consent your setting and the law require (written consent for Part 2 records).
If your client records are covered by 42 CFR Part 2, check with your privacy officer before entering any session text into Reframe, even with names removed.
FAQ
How do you write a DAP note for a substance use session?
Data holds the amounts used since the last session, what the client reported, what you observed, your interventions and the risk check. Assessment interprets that against the client's goal and states risk with its reasoning. Plan records what the client agreed to try, any referral and the next appointment.
How do I record alcohol use in a progress note?
Record the number of drinking days and the standard drinks per drinking day, ideally day by day for the past week. A weekly total makes change easy to see from one session to the next.
How do I document motivational interviewing in a progress note?
Name the skills you used, such as open questions, affirmations, reflections and importance and confidence rulers, and record what the client said for and against change. Ruler scores give you a number to compare across sessions.
What language should I use about substance use in notes?
Person-first, descriptive language: "a client who uses alcohol" rather than a label, "tested negative" rather than "clean", and what the client said rather than "in denial". The note should describe what happened, not judge it.
This page is educational. Adapt the template to your licensing board, your payer and your setting.
Reframe Practice is a tool for licensed therapists, not a therapy clinic or counseling service.