Addiction session notes: what to note and how to track use over time

Why addiction notes are different

In addiction care, a session note is also a measuring tool. Use goes up, comes down, stops and sometimes starts again. If it is written down differently at each session, you can no longer tell after six months whether things are improving.

• Follow-up is long and full of ups and downs. Starting again after several weeks without using is part of the path for many patients.
• Motivation shifts. A patient may want to stop one day and no longer see the point a fortnight later.
• Several professionals are involved. The note must be readable by someone other than you.

This article covers follow-up, session after session. For the first consultation and the summary letter, see our addiction consultation report template. For the general framework, see psychologists' session notes.

What to note at every session

These headings work for most substances. Fill them in the same way every time.

Use since the last session

One block per substance. The number of days of use, the amount on a typical day, the heaviest day, and the route of use when it changes the risk. Figures rather than "less than before".

Cravings and their triggers

The intensity of craving from 0 to 10 as rated by the patient, how often it occurs and the triggers (a place, a time of day, a person, an emotion).

High-risk situations

Those the patient went through, what they did and whether it worked. Those coming up (a wedding, holidays, an anniversary).

Lapses and relapses

Note what happened before (situation, emotion, thought), during (amount, duration), after (how the episode ended) and how the patient reads it. "Had 8 drinks on Saturday evening after an argument with his sister, stopped on his own on Sunday" says more than "relapse".

Motivation and goal

The goal is not always to stop. It may be to cut down or to use with less risk. Note the goal as the patient puts it, and whether it has changed.

Harm reduction

What was discussed to limit harm, even without stopping. Not driving, avoiding certain combinations, not using alone.

Health and treatment

Treatment and how it is going, sleep, mood, withdrawal signs. If you assessed suicide risk, note what you assessed and what was decided (see our crisis session note template).

Measuring use so you can compare

The most common flaw is amounts written as "beers" one time and "bottles" the next. Three rules prevent it.

Rule 1. Convert everything into standard units

In France, a standard drink contains 10 g of pure alcohol. The HAS (Haute Autorité de santé, the French national health authority) gives as equivalents 10 cl of wine at 12%, 25 cl of beer at 5% or 3 cl of spirits at 40%. To convert another drink, multiply the volume in ml by the strength, divide by 100, then multiply by 0.8 to get grams. A 50 cl can at 8% therefore contains about 32 g of alcohol, a little over 3 standard drinks.

Cannabis has no standard unit. Agree with the patient on a unit they can estimate (joints, grams) and keep it. With no established threshold, the HAS working group chose one joint a week as the significant level for offering a brief intervention.

Rule 2. Rebuild day by day on a calendar

The reference method is the Timeline Followback (TLFB) by Linda and Mark Sobell, described in a reference chapter published in 1992. The patient rebuilds their use day by day on a calendar, using landmarks (weekends, paydays, celebrations). According to its authors, the period covered usually ranges from 7 days to 24 months.

The official TLFB forms, French version included, are protected by copyright, and their authors ask for permission even for clinical use. The principle itself works with an ordinary calendar. At the start of the session, begin with yesterday and work back day by day to the previous session.

Rule 3. Keep the same reference period

Write for example "over the last 14 days", and convert to 30 days if the session rhythm changes. Three figures are enough to follow the trend. Days of use, total standard drinks, days above 2 drinks.

Validated questionnaires, at regular intervals

Note the tool, the date and the total score, without copying the questions.

• AUDIT (WHO)
  • What it measures. Alcohol use over the past year, 10 questions.
  • Reading. Score from 0 to 40, four zones (0 to 7, 8 to 15, 16 to 19, 20 and above). From 20, the WHO manual points to a specialist assessment.
• FACE
  • What it measures. Alcohol use, a short questionnaire chosen for the HAS screening tool.
  • Reading. Scoring and thresholds in the HAS tool (updated in 2021).
• CAST (OFDT)
  • What it measures. Problematic cannabis use, 6 questions scored from 0 to 4.
  • Reading. A score of 7 or more suggests probably problematic use.

These are screening tools, not diagnostic ones. At the start of follow-up and then about every three months is enough to see a trend.

Alcohol guidelines in France

Since 2019, Santé publique France (the French public health agency) and the Institut national du cancer (French National Cancer Institute) have promoted these guidelines. No more than 10 drinks a week, no more than 2 drinks a day, and some days without drinking each week. The public message is « Pour votre santé, l'alcool c'est maximum 2 verres par jour, et pas tous les jours » (for your health, alcohol means 2 drinks a day at most, and not every day).

In the note, they help place the patient's use. The goal remains the one the patient chooses.

Motivational interviewing: what to keep in the note

The HAS describes motivational interviewing as an empathic approach that strengthens the patient's wish to change while respecting their choices and their ambivalence. Four elements deserve a written trace.

• The stage of change. Prochaska and DiClemente's model distinguishes precontemplation (the patient sees no problem), contemplation (they are unsure), preparation, action and maintenance. Note the stage you observe and what makes you think so. A step back is noted without judgement.
• The patient's own words. Change talk covers what they say in favour of change (desires, abilities, reasons, needs, commitments). Sustain talk covers what they say in favour of the status quo. One or two quotes, read again three months later, show how things have moved.
• Importance and confidence from 0 to 10. The HAS lists these scales among the tools of brief intervention. Note both figures and the reason the patient gives for not choosing a lower one.
• What you offered and how the patient reacted. Above all, note what the patient did with it. A decision they make themselves should appear in their own words.

The French setting: private practice, CSAPA, CJC, ELSA

• CSAPA (centre de soins, d'accompagnement et de prévention en addictologie, specialist addiction treatment and prevention centre)
  • Who it serves and how. Free access, anonymous if the person wishes. Medical, psychological and social assessment, care, harm reduction, opioid substitution treatment.
  • What it means for the note. The file is often shared. Write so the whole team can understand.
• CJC (consultation jeunes consommateurs, young users' clinic)
  • Who it serves and how. Free, anonymous service for 12 to 25 year olds and their families, from the earliest stages of use.
  • What it means for the note. Keep apart what comes from the young person and what comes from their relatives.
• ELSA (équipe de liaison et de soins en addictologie, hospital addiction liaison team)
  • Who it serves and how. A hospital team that sees inpatients or patients in the emergency department and advises ward staff.
  • What it means for the note. Notes are often one-off. State the referral offered and who takes over.
• Private practice
  • Who it serves and how. Psychologist, psychiatrist or addiction physician, often working with the GP.
  • What it means for the note. You are often the only reader. Keep the same structure at every session.

Confidentiality and sensitive data

Health data fall under a specific legal regime, which the CNIL (French data protection authority) justifies by their sensitivity. In addiction care, notes may also mention illegal behaviour, third parties or legal proceedings.

• Note what is useful for care. That the patient buys cannabis is useful. The seller's name, places and amounts are not.
• Refer to third parties by their role. "His sister", "a colleague", rather than names.
• Describe rather than label. "Has been drinking every day for two years" rather than a word that judges the person. The patient can ask to read their file, and other clinicians may read it too.
• Keep care and the justice system apart. When treatment is court-ordered, the content of sessions remains covered by confidentiality. Our article on the confirmation of ongoing care explains what you can write.

See also our articles on professional confidentiality and AI and on how long to keep patient files.

A ready-to-use session note template

Copy this template into your patient files. It fits on one page.

• Setting. Date, session number, place, people present.
• Use. Per substance, since the last session. Days of use, total in standard units, heaviest day, days above the guideline, days without use.
• Cravings. Intensity from 0 to 10, frequency, triggers.
• High-risk situations. Those faced (strategies used, effective or not) and those ahead.
• Lapses or relapses. Before, during, after. The patient's reading.
• Motivation. Stage observed, importance and confidence from 0 to 10, one or two quotes from the patient.
• Current goal. Stopping, cutting down or lower-risk use, in the patient's words.
• Harm reduction. Topics discussed and what the patient takes from them.
• Health and treatment. Treatment, sleep, mood, withdrawal, risk assessment if done.
• Questionnaire. Tool, date, score (only when it was used).
• Analysis. Two or three sentences on the trend and what moves it.
• Plan. Goal until the next session, exercise, any referral, next appointment.

A completed example (fictional patient)

Mr R., 46, sees a private practitioner about his drinking. Motivational interviewing and cognitive behavioural therapy, one session every two weeks. Session 9, fourth month.

• Use. Alcohol over the last 14 days, rebuilt day by day. 6 days of use, 19 standard drinks. Heaviest day Saturday the 4th (7 drinks). 2 days above 2 drinks, 8 days without alcohol. No other substance.
• Cravings. 6/10 around 7 pm on the way home from work, 3 to 4 times a week. Triggers, the commute home and tiredness.
• High-risk situations. Replaced the evening drink with a 20 minute walk 4 evenings out of 5, successfully. A friend's wedding in three weeks, which worries him.
• Lapses or relapses. Saturday the 4th, 7 drinks at a family meal after a remark from his father about his job. Stopped on his own around 11 pm. The next day, "I felt like I'd ruined everything".
• Motivation. Action stage. Importance 8/10, confidence 6/10 ("not 4, because I held out during the week"). Names his son as the main reason.
• Current goal. Cutting down. No alcohol on weekdays, 2 drinks at most at weekends. Unchanged.
• Questionnaire. AUDIT at session 1, score 21. Next one at session 12.
• Analysis. Clear, steady drop on weekdays. Lapses remain linked to family settings. Reading a single lapse as "ruined everything" needs work.
• Plan. Prepare for the wedding (written plan, alcohol-free drinks, time to leave). Keep the daily calendar. Next session in 14 days.

Put side by side, his notes show the curve of his follow-up.

• Month before follow-up. 27 days of use, 148 standard drinks, 24 days above 2 drinks.
• Month 2. 19 days of use, 81 standard drinks, 12 days above 2 drinks.
• Month 3. 15 days of use, 52 standard drinks, 6 days above 2 drinks.
• Month 4. 12 days of use, 39 standard drinks, 4 days above 2 drinks.

Shown in session, this summary helps the patient see Saturday's lapse as one point in a falling trend.

How Delta works

During the session, Delta transcribes what is said, then prepares a session report that you review. You can also dictate your observations right after the session. The report takes into account your specialty and your therapeutic approach, and it is added to the patient's file. The file brings out the progress specific to your approach over the sessions. In addiction care, that means seeing how a patient's use changes over several months. Delta also drafts your assessment reports, letters and certificates.

Data is hosted in France, with a host certified for health data (HDS). AI processing, transcription included, takes place on servers located in France. The patient's name and identifying information are pseudonymised before going through the AI, no audio file is kept, data is never used to train models and it is encrypted in transit and at rest. For informing the patient, see our article on consent and 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 and brief intervention tool (2014, updated 2021)
• Santé publique France, Alcool et santé : améliorer les connaissances et réduire les risques (2019)
• Santé publique France, Usage problématique de cannabis : outils et structures pour le repérage et l'accompagnement
• ARS Hauts-de-France, Prise en charge et accompagnement des addictions (2025)
• Babor et al., AUDIT: The Alcohol Use Disorders Identification Test, Guidelines for Use in Primary Care, WHO, 2001
• Sobell L.C., Sobell M.B., Timeline Follow-Back: A Technique for Assessing Self-Reported Alcohol Consumption, Humana Press, 1992
• Nova Southeastern University, Timeline Followback forms
• Prochaska J.O., DiClemente C.C., Stages and processes of self-change of smoking, 1983
• SAMHSA, TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment, chapter 3 (2019)
• CNIL, Qu'est-ce qu'une donnée de santé ?
• Conseil Supérieur de la Santé, Boissons alcoolisées et risques pour la santé (2018)
• CFANT, Consommation d'alcool : « moins c'est mieux » (2026)