Addiction consultation report: template, example and letter to the GP

What the first consultation report is for

This document sets a starting point: the person's situation on the day they arrive. Without it, it is hard to measure later what has changed. It also helps you decide (supervised withdrawal, referral, physical health check) and it is the basis of the letter to the GP.

You write it after the first consultation, in private practice, in a CSAPA (Centre de soins, d'accompagnement et de prévention en addictologie, the French specialist addiction treatment centres) or in hospital, or after an opinion requested by a colleague. The assessment rarely fits into one meeting. Complete the report over two or three consultations and date each addition.

For follow-up session by session, see our guide to addiction session notes. For the life history in a broader sense, the first session anamnesis template is still useful.

The framework: confidentiality, sharing and who does what

What the person shares is covered by professional confidentiality (medical confidentiality for doctors, article 7 of the 2021 French psychologists' code of ethics for psychologists).

Within the same care team, article L1110-4 of the “Code de la santé publique” (French Public Health Code) allows professionals to share the information that is strictly necessary, provided the person is informed and can object. Outside the care team, their prior consent is required. Psychologists share only what is strictly necessary (article 8 of their code).

• Write knowing that the person can ask to read their file. Describe facts and what was said, without judgement. See our article on patient access to their file.
• Stay within your remit. Prescribing, medication-assisted withdrawal and blood tests are for the doctor.
• Note what helps care. Where drugs are bought, the names of third parties or details of possible offences do not belong in the file.

The template, section by section

A section with nothing to report can take one line, but note that it was explored.

1. Header and context of the request

Date, length, place. Who referred the person. The context, for example court-ordered treatment, because the request then does not come only from the person. What the person expects, in their own words.

2. Substance use history, substance by substance

One line per substance, including tobacco and medicines (benzodiazepines, opioid painkillers). For an addiction without a substance, such as gambling, the same logic applies.

• Onset. Age at first use and at regular use.
• Course. Periods of increase, stopping and relapse, with the events around them.
• Current use. Quantity, frequency, times of day, over the last 7 days.
• Route. Drunk, smoked, snorted, injected, swallowed. Alone or with others. Sharing of equipment.
• Function. What the substance does for the person (sleep, calming anxiety).

Note precise quantities. For alcohol, a standard drink served in a bar contains 10 g of pure alcohol, for example 10 cl of wine at 12% or 25 cl of beer at 5% (HAS, Haute Autorité de Santé, the French National Authority for Health). The French lower-risk guidelines from Santé publique France (the French public health agency) are no more than 10 standard drinks a week, 2 a day, with alcohol-free days. “3 to 4 glasses of wine every evening” can be compared in six months, “drinks a bit” cannot.

3. Screening questionnaires

Note the name, the date and the score, without copying the items. The HAS screening tool (updated in 2021) uses the FACE for alcohol, suggests the CAST for cannabis and mentions the WHO ASSIST, which covers several substances. A score helps you compare over time. It does not replace the interview.

4. Substance use disorder criteria

The DSM-5 describes substance use disorder with 11 criteria, looked for over the last 12 months. For alcohol, they cover loss of control (including intense craving), consequences on daily life (obligations, relationships, activities given up), risky use (dangerous situations, continuing despite a health problem) and pharmacological signs (tolerance, withdrawal). Two or three criteria indicate a mild disorder, four or five a moderate disorder, six or more a severe disorder.

List the criteria found with a concrete example for each, then the severity. As a psychologist, you can write that the picture “suggests” a substance use disorder, leaving the medical diagnosis to the doctor.

5. Withdrawal, stopping and relapse

• Current withdrawal signs (shaking or sweating in the morning, needing to use on waking).
• Past withdrawals and their complications (seizures, hallucinations, confusion).
• Longest period without use and what came before relapse.
• Treatments already received.

Complications during a past withdrawal, strong physical dependence, high-dose benzodiazepine use or severe hardship point towards supervised withdrawal, sometimes in hospital (La Revue du Praticien, 2021).

6. Associated mental health conditions

Mood, anxiety, sleep, trauma, attention, psychotic disorders, eating disorders. Note what comes before the use and what seems to follow from it, and any current care. See also our mental status examination template.

7. Physical health

Known health problems, treatments, pregnancy, last check-up. What to explore depends on the substance (liver for alcohol, lungs for tobacco and smoked cannabis, hepatitis C and HIV with injecting or shared equipment). Psychologists note what the person reports and refer them to their doctor.

8. Social situation

Housing, income, work, people around them, dependent children, driving licence, legal situation linked to use, available support. It often shapes the referral.

9. Risk assessment

• Suicidal thoughts, past attempts, access to means. If risk is present, see our crisis session note.
• Overdose risk, especially with mixing (alcohol, benzodiazepines, opioids) or using again after a break.
• Driving under the influence.
• Violence experienced or committed, children put at risk.

Note the level of risk you settle on and what you did. For opioids, state whether naloxone (the overdose antidote, some forms of which are sold without prescription in French pharmacies) was offered.

10. The person's motivation and goal

What the person wants to change, in their own words. The HAS tool suggests rating on a scale how important the change is to them and how confident they are that they can make it. Note both numbers. The HAS also points out that relapse is more often the rule than the exception.

11. Summary

Three to five sentences. Main substance and other substances, severity, priority risks, associated conditions to explore, the person's point of view. This is what a busy colleague will read.

12. Care plan and referral

The goal is decided with the person. The Société française d'alcoologie (French Alcohol Society, 2015 guidelines) asks clinicians to accept the goal chosen by the patient at the initial assessment, whether reducing or stopping. Note it with the planned steps and the next appointment.

• Strong physical dependence, complicated withdrawal in the past. Medical opinion before any stop, supervised withdrawal, sometimes in hospital.
• Need for medical, psychological and social follow-up. CSAPA, anonymous and free.
• Person far from care, infection risk. CAARUD (French harm reduction centres for people who use drugs).
• Medication to discuss. GP, addiction specialist or psychiatrist.
• Mental health condition in the foreground. Psychiatrist or psychologist, linked with the addiction follow-up.

See also our individualised treatment plan template.

Filled-in example

Fictional case. Any resemblance to a real person is coincidental.

Header. First addiction consultation, CSAPA, 50 minutes. Mrs R., 46, referred by her GP. Her request, “drink less, I can't stop in the evening any more”.

Use. Regular alcohol use for 8 years, rising since her separation 2 years ago. 4 glasses of wine (12 cl) every evening from Sunday to Friday and 7 to 8 on Saturday, about 35 to 40 standard drinks a week. Drinks alone, to “unwind” and to fall asleep. Tobacco, 10 cigarettes a day. Cannabis, a few joints a year. No other substance, no benzodiazepines.

Screening. FACE questionnaire today, score of 10, to compare at the next consultations.

Criteria over 12 months. Drinks more than planned almost every evening. Two failed attempts to cut down. Strong craving at the end of the day. Continues despite repeated arguments with her ex-partner. Tolerance (“I need more to sleep”). Five criteria, picture suggesting a moderate alcohol use disorder.

Withdrawal. No morning shaking or sweating. No previous withdrawal. Longest period without alcohol, 3 weeks in January, relapse after an argument.

Associated conditions. Poor sleep and evening anxiety since the separation. No current care.

Physical health. Recent blood test ordered by the GP, results not brought.

Social situation. Manager, in work. Two children aged 12 and 15 in shared custody. A supportive sister.

Risk. No suicidal thoughts. Drove twice after drinking this month. Risk discussed, arrangement found with her sister for evening journeys.

Motivation. Importance 8 out of 10 (“for the children”). Confidence 4 out of 10 (“in the evening I give in”).

Summary. Moderate alcohol use disorder, no reported sign of physical dependence, used to calm herself. Road risk. Associated smoking. High motivation, low confidence.

Care plan. Mrs R. chooses to cut down, with no more than 2 drinks an evening and 2 alcohol-free days a week. Stopping not wanted for now, topic left open. Appointment with the CSAPA doctor (medication to help, tobacco). Psychological follow-up accepted. Letter to the GP with her agreement. Review in 10 days with a drinking diary.

The letter to the GP

The letter keeps only what the doctor needs to care for the person well.

Before writing, the person's agreement

For the consulted doctor, article R4127-58 of the Code de la santé publique (amended in July 2026) requires informing the “médecin traitant” (the patient's registered GP) of their findings and decisions, unless the patient objects, and noting this in the medical file. For psychologists, articles 8 and 15 of their code require sharing only what is necessary, with the person's assent or after informing them.

In practice, say at the end of the consultation what you are going to write and what you will leave out, then note their answer. If they refuse, respect that choice and note that you explained why the letter would help.

What goes in

• The reason, the date and who asked for the consultation.
• The substances and current quantities, in clear units.
• The conclusion in one sentence.
• The risks that concern the doctor (withdrawal, interactions, driving, overdose).
• The goal agreed with the person and the next steps.
• What you expect from the doctor, as a question or a proposal.

What stays out

• The detail of the sessions and personal disclosures unrelated to care.
• Information about third parties (partner, children, people around them who use).
• Where drugs come from and anything that reads like an admission of an offence.
• Judgements (“denial”, “manipulation”).
• For psychologists, any suggestion of medication.

Example letter

Continuing the fictional case.

Dear Doctor, on 2 October I saw Mrs R., 46, whom you referred to me about her alcohol use. She describes 35 to 40 standard drinks a week, mostly in the evening. The picture suggests a moderate alcohol use disorder, with no morning withdrawal signs and no previous withdrawal. She smokes 10 cigarettes a day.

Mrs R. wants to cut down first. Together we set a goal of no more than 2 drinks an evening and 2 alcohol-free days a week. I warned her about driving after drinking. She will see the centre's doctor and is starting psychological follow-up.

The results of her recent blood test would be useful to us. Mrs R. agrees to my sending you this letter. Kind regards.

For a full letter template, see the psychologist's letter to the doctor or the psychiatrist's letter to the GP.

Common mistakes

• Vague quantities. Write drinks, grams, joints, days.
• Only one substance explored. Tobacco, medicines and mixing change the risks.
• A conclusion without criteria. It cannot be checked or tracked.
• Past withdrawal forgotten. It weighs on the choice of supervised withdrawal.
• An imposed goal. Writing “abstinence” when the person wants to cut down weakens the therapeutic relationship.
• Judgemental wording. Describe what the person says and does.
• A letter that copies the report. Five useful lines are often enough.

How Delta works

Delta is an AI assistant for mental health professionals and allied health practitioners. During the consultation, Delta transcribes what is said, then prepares a report that you review. You can also dictate your observations just after. The report is added to the patient's file.

Delta takes your specialty and your therapeutic approach into account. In addiction care, the file brings out the progress specific to this kind of follow-up, for example how the patient's use changes over several months. Delta also drafts your assessment reports, letters and certificates, which you review before sending.

Data is hosted in France by a provider certified for health data (HDS). AI processing, including transcription, runs on servers located in France. The patient's name and identifying details are pseudonymised before they reach the AI, no audio file is kept, data is never used to train models and it is encrypted in transit and at rest. On informing patients, see our article on consent to AI note-taking.

Frequently asked questions

Sources

• HAS, Outil d'aide au repérage précoce et intervention brève : alcool, cannabis, tabac chez l'adulte (updated 2021)
• HAS, development report for the early screening tool, 2014, updated 2021 (PDF)
• Santé publique France, Alcool et santé : améliorer les connaissances et réduire les risques (2019)
• NIAAA, Alcohol Use Disorder: A Comparison Between DSM-IV and DSM-5
• French National Medical Council, article 58 of the medical code of ethics (R4127-58)
• Code de déontologie des psychologues, 2021 updated version (PDF)
• MACSF, Secret médical partagé et équipe de soins (articles L1110-4 and L1110-12 of the Code de la santé publique)
• ARS Île-de-France, addiction care facilities (CSAPA, CAARUD)
• La Revue du Praticien, Sevrage alcoolique : comment faire en pratique ? (2021)
• French National Order of Pharmacists, Surdosage et overdose d'opioïdes : point de l'ANSM sur la naloxone (2023)