Understanding the Treatment Assessment Process

When an adult or adolescent enters treatment for a substance use disorder or a mental health disorder, the first step in the process is an assessment. An assessment evaluates the person’s individual needs and the level of care they need.

The goal of an assessment is to determine appropriate treatment options and provide a recommendation. The assessment team looks at substance use, medical history and mental health. Age, gender and cultural background are also taken into consideration.¹

How long does a treatment assessment last?

A typical treatment assessment will take about 90 minutes. Physical exams last about one hour, and psychiatric evaluations last approximately two hours. Parents must attend an adolescent assessment.

Substance abuse assessment

A substance abuse assessment gives the treatment center an overall picture of a person’s substance abuse disorder. This phase of the assessment takes a complete history of drug and alcohol use. Points examined include:

• All substances being abused
• How much the person drinks or takes drugs
• How long the person has been drinking or taking drugs
• When the last drink or drug was consumed
• Any history of withdrawals
• Any prior treatment attempts

Physical assessment

A physical exam gives the treatment center a complete picture of the person’s medical condition. When substance abuse is involved, the exam helps identify any withdrawal symptoms. A drug and alcohol screen is administered to see what substances are present in a person’s system.

Other medical conditions are also investigated. Tests for TB, HIV/AIDS and other infectious diseases are usually conducted. Testing also includes blood count and electrolyte levels. Major organ functions are also examined.

Mental health assessment

A mental health assessment gives the treatment center a complete picture of a person’s psychiatric condition.

A healthcare professional asks questions to determine the person’s emotional state. The assessment also looks at how well the individual is able to think, reason and remember.

The person is asked how they feel at the present moment and if they get along with other people. Observations about mood, behavior and how well the person is able to express emotions and thoughts are noted.

Adolescent assessment

Adolescent examinations are similar to adult examinations. Some parts of teen assessments are conducted without the parents, and other parts include parents. The assessment team also interviews parents about their child’s substance abuse problems, psychiatric symptoms, behavioral problems and medical history.

What to bring to an assessment

• Any medical or psychiatric records
• Prescription medications being taken
• A list of over-the-counter medications needed

If you’re a parent attending your child’s assessment, bring along your child’s school records and any documents you have from counselors, psychiatrists, teachers and caregivers. These records help the assessment team develop a comprehensive picture of your adolescent.

Proper diagnosis

A great deal of sensitive information is shared during assessment, and the process may have challenges. Honest communication between the client and the assessment team helps support getting a proper diagnosis and the best treatment plan possible.²

References:

1. https://www.drugabuse.gov/publications/seeking-drug-abuse-treatment/2-does-program-tailor-treatment-to-needs-each-patient
2. https://pro.psychcentral.com/14-tips-for-the-diagnostic-interview-of-mental-disorders/005295.html