This comprehensive Alcohol Biopsychosocial Assessment provides a structured way to evaluate alcohol use, related consequences, withdrawal risk, mental health concerns, legal history, readiness for change, and treatment needs. It includes standardized alcohol screening results, DSM-5-TR Alcohol Use Disorder symptom review, ASAM-informed clinical domains, risk and protective factors, and individualized recommendations. The assessment is designed for professional clinical use and may also support court-related documentation when appropriate.
Comprehensive Alcohol Biopsychosocial Assessment | Mark Zauss, LMHC
Clinical Assessment • Alcohol & Substance Use

Comprehensive Alcohol Biopsychosocial Assessment

A structured clinical assessment for alcohol-related concerns, including drinking history, standardized screening results, DSM-5-TR Alcohol Use Disorder symptom review, withdrawal risk, legal and psychosocial history, readiness for change, ASAM-informed domains, diagnostic impression, and treatment recommendations.

Mark Zauss, BC-TMC, LMHC, LPC, CCMHC, NCC, ASDCS, CCTP, CCTP II, NATC, ADHD-CCSP, C-DBT, C-PD
Double Board Certified Counseling Services, Inc.
Important

Purpose and Scope

This tool is designed as a clinical alcohol/substance-use biopsychosocial assessment. When the evaluator is also the individual's treating therapist, it should not be represented as an independent forensic evaluation. The evaluator should distinguish client self-report, records reviewed, collateral information, behavioral observations, and clinical opinion.
This assessment does not determine guilt, innocence, legal responsibility, credibility, sentencing, or other legal conclusions. Court, probation, diversion, or attorney requirements should be verified before relying on this assessment for a specific legal purpose.
1

Identifying Information

2

Reason for Referral & Sources of Information

3

Mental Status & Behavioral Observations

4

Presenting Incident

5

Alcohol Use History

6

AUDIT-C / AUDIT Screening Results

Enter results from the official screening instruments rather than reproducing the full instrument here. Screening results support clinical assessment but do not independently establish a diagnosis.
7

DSM-5-TR Alcohol Use Disorder Symptom Review

Rate each domain based on symptoms occurring within the same 12-month period. The automated count is descriptive and requires clinical confirmation.
Supported criteria: 0 / 11No AUD severity automatically assigned until clinical review.
8

Consequences & Functional Impact

9

Blackout & Withdrawal History

Safety: previous withdrawal seizures, delirium, severe autonomic symptoms, or sustained heavy alcohol use may indicate risk for medically dangerous withdrawal and require medical evaluation.
10

Other Substance Use & Medications

11

Medical & Mental Health History

12

Safety Assessment

13

Legal History

14

Current Psychosocial Functioning

15

Risk & Protective Factors

Risk Factors

Protective Factors

16

Readiness for Change

17

ASAM-Informed Multidimensional Clinical Review

This section is ASAM-informed and is not represented as the proprietary ASAM Criteria placement instrument. The Fourth Edition uses six updated dimensions and integrates readiness to change across treatment planning.
Clinical DomainConcern LevelComments
1. Intoxication, withdrawal & addiction medication needs
2. Biomedical conditions
3. Psychiatric & cognitive conditions
4. Substance-use-related risks
5. Recovery environment interactions
6. Person-centered considerations
18

Clinical Formulation & Diagnostic Impression

19

Treatment Recommendations

20

Automated Clinical Summary

This summary is rule-based and non-diagnostic. Review and edit it before using it in a clinical record, attorney communication, or court-related document.
Complete the assessment and select “Score + Clinical Summary.”
21

Limitations & Clinician Attestation

Attestation: I certify that the information and clinical opinions contained in this assessment reflect my professional assessment based upon the information available at the time of evaluation.

22

Electronic Signatures & Automatic Dates

Electronic signatures below are applied by typing the signer's legal name, affirming the signature acknowledgment, and selecting the signature button. The page automatically records the local date and time on the device used to sign. Review any court, attorney, agency, or organizational requirements regarding acceptance of electronic signatures before submission.

Client Electronic Signature

Clinician Electronic Signature

The automatic completion date/time is populated when the first electronic signature is applied. It may be updated by clearing both signatures and signing again.

Clinical References

Clinical & Educational Sources

World Health Organization. AUDIT: The Alcohol Use Disorders Identification Test—Guidelines for Use in Primary Care.
https://www.who.int/publications/i/item/WHO-MSD-MSB-01.6a

National Institute on Alcohol Abuse and Alcoholism. Alcohol Use Disorder: From Risk to Diagnosis to Recovery.
https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/alcohol-use-disorder-risk-diagnosis-recovery

American Society of Addiction Medicine. The ASAM Criteria, Fourth Edition.
https://www.asam.org/asam-criteria/asam-criteria-4th-edition

The ASAM-informed section on this page does not reproduce the proprietary ASAM Criteria placement instrument and should not be represented as an official ASAM Criteria Level of Care Assessment.

Educational and clinical use notice: This page is intended to support professional clinical assessment and documentation. It does not replace individualized legal advice, emergency medical evaluation, formal forensic evaluation, or a court-mandated assessment by a specifically designated provider.