Copy this DAST documentation template for your next substance use screening
A DAST documentation template gives clinicians a structured place to record a Drug Abuse Screening Test administration, score, clinical interpretation, client response, and follow-up plan. Use the template below as a copyable documentation aid for intake notes, assessment updates, treatment planning, or periodic substance use screening.
This is a documentation template, not a substitute for the official screening tool, your organization’s scoring instructions, or clinical judgment. If your practice uses the DAST-10 or another version of the Drug Abuse Screening Test, administer and score that tool according to your approved workflow, then document the results in a clear clinical note.
Blank DAST documentation template
Client Name/ID: Date of Service: Clinician: Service Type: Intake / Assessment / Individual Therapy / Other: Screening Tool Used: DAST version administered: Reason for Screening: Relevant Presenting Concerns: Administration Method: ☐ Self-administered ☐ Clinician-administered ☐ Completed during intake ☐ Completed during follow-up session ☐ Other: Client Substance Use Context: Client reports: - Substances discussed: - Frequency/pattern of use: - Recent changes in use: - Client-identified concerns: - Relevant medical, psychiatric, legal, occupational, relational, or safety concerns: DAST Responses: All required items completed? ☐ Yes ☐ No If no, explain omitted items or barriers: DAST Score: Total score: Scoring guide/range used: Clinical interpretation: ☐ No indicated concern based on score ☐ Low indicated concern ☐ Moderate indicated concern ☐ High indicated concern ☐ Other/clinician interpretation: Clinical Observations: Client presentation during screening: Client affect, insight, motivation, ambivalence, or distress: Client response to score/results: Risk and Safety Considerations: Current intoxication observed or reported? ☐ Yes ☐ No Withdrawal concerns reported? ☐ Yes ☐ No Overdose risk factors discussed? ☐ Yes ☐ No Safety plan, crisis plan, or medical referral indicated? ☐ Yes ☐ No Details: Clinical Impression: Summary of screening results and clinical meaning: Relationship to presenting problem, diagnosis, or treatment goals: Limitations of screening results: Plan / Follow-Up: ☐ Discussed results with client ☐ Provided psychoeducation ☐ Added or updated treatment plan goal ☐ Planned continued monitoring ☐ Referred for substance use assessment or higher level of care ☐ Coordinated care with appropriate consent ☐ Other: Next Steps: Client-stated goal or preference: Clinician recommendation: Planned reassessment date or interval:
Completed DAST documentation example
The sample below shows how a clinician might document DAST results inside an intake or assessment note. Adapt the wording to your setting, payer requirements, clinical scope, and the specific version of the DAST your practice uses.
Sample DAST documentation entry
Client Name/ID: J.R. Date of Service: 05/14/2026 Clinician: M. Smith, LCSW Service Type: Intake assessment Screening Tool Used: DAST-10 Reason for Screening: Client presented for intake with anxiety, sleep disruption, and relationship conflict. Substance use screening was completed as part of routine behavioral health assessment. Administration Method: Clinician-administered during intake session. Client Substance Use Context: Client reported cannabis use most evenings after work and non-prescribed use of a stimulant medication on two occasions during the past month. Client denied current alcohol-related concerns and denied opioid use. Client reported increased conflict with partner related to cannabis use and stated, “I do not like that I need it to sleep.” DAST Responses: All required items completed? Yes. No items omitted. DAST Score: Total score: 4 Scoring guide/range used: Clinic-approved DAST-10 scoring guide. Clinical interpretation: Score falls in the moderate concern range per clinic scoring guide. Clinical Observations: Client was cooperative and engaged throughout screening. Affect was anxious but stable. Client demonstrated partial insight into the relationship between substance use, sleep, avoidance, and partner conflict. Client expressed ambivalence about reducing cannabis use but was open to tracking use between sessions. Risk and Safety Considerations: Client denied current intoxication, withdrawal symptoms, overdose history, and current suicidal or homicidal ideation. No immediate medical referral indicated during this session. Clinician provided education on monitoring for increased use, impaired functioning, and withdrawal-related concerns. Clinical Impression: DAST results suggest clinically relevant substance use concerns that may be contributing to sleep difficulty, anxiety management patterns, and relationship stress. Results will be used to inform treatment planning and continued assessment. Screening result is not used as a standalone diagnosis. Plan / Follow-Up: Clinician reviewed results with client and provided psychoeducation on substance use, sleep, and anxiety cycles. Client agreed to track cannabis use, sleep quality, and anxiety rating before next session. Treatment plan will include a goal related to coping skills and reduction of substance-related impairment. Clinician will reassess substance use in four sessions or sooner if risk changes.
When to use a DAST documentation template
A DAST documentation template is most useful when substance use may be clinically relevant, but the session note needs more than a score. The score matters. The clinical context matters too.
Many therapists use this type of template during intake, reassessment, treatment plan reviews, or sessions where a client reports new or increased drug use. It can also support consistent documentation across clinicians in a group practice, especially when each provider needs to record the same core elements: tool administered, score, interpretation, client response, risk factors, and follow-up plan.
Common clinical situations
- Initial intake includes routine substance use screening.
- A client reports increased cannabis, stimulant, sedative, or other drug use.
- Treatment goals include coping skills, relapse prevention, or harm reduction.
- A payer, program, or agency requires periodic screening documentation.
The template can also help when substance use is not the primary presenting problem. For example, a client in therapy for anxiety may report using cannabis nightly to sleep. A DAST score, paired with clinical observations and a follow-up plan, gives the note a clearer connection between screening results and treatment direction.
What to include in a strong DAST note
A strong DAST note should show what was administered, what the results were, how the client responded, and what the clinician did with the information. Avoid documenting the score alone. A score without interpretation or follow-up leaves the next clinician, auditor, or reviewer guessing.
Core documentation elements
At minimum, include the screening tool version, date administered, method of administration, total score, scoring reference used by your practice, clinical interpretation, and next steps. If the client did not complete all items, document why. If the client declined screening, document the refusal and any clinical follow-up.
Clinical observations can be brief but should add value. For example, “Client appeared guarded and minimized consequences” tells the reader more than “DAST completed.” A useful note may also describe ambivalence, insight, readiness to change, emotional response, or stated goals.
Risk and safety details
Substance use screening may raise concerns that need follow-up. If clinically relevant, document intoxication, withdrawal concerns, overdose history, risky routes of administration, impaired driving, medication interactions, pregnancy-related considerations, or co-occurring suicidal ideation. Not every DAST note needs every risk detail, but the note should reflect the concerns that were actually assessed.
How to connect DAST results to the treatment plan
The DAST should not sit in the chart as an isolated form. If results are clinically meaningful, connect them to the treatment plan. This is especially helpful when substance use affects mood, sleep, relationships, work, school, legal involvement, or medication adherence.
A practical treatment plan connection might look like this:
Treatment Plan Link: Problem Area: Substance use contributing to anxiety, sleep disruption, and relationship conflict. Goal: Client will reduce substance-related impairment and develop alternative coping strategies. Objective: Client will track use patterns and identify two triggers for use before next session. Intervention: Clinician will provide psychoeducation, motivational interviewing, coping skills training, and referral options as clinically indicated.
This type of language helps show how the screening informed care. It also keeps the note clinically grounded. The goal is not to overstate the result. The goal is to document how the screening affected assessment, planning, and follow-up.
Common DAST documentation mistakes to avoid
Recording only the score
“DAST score: 4” is usually not enough. Add the version used, scoring guide, interpretation, client response, and plan. A short explanation can make the result clinically meaningful.
Using the score as a diagnosis
A screening result can support assessment, but it is not the same as a diagnosis. If you diagnose a substance use disorder, document the clinical criteria, history, impairment, and differential considerations required by your practice standards.
Leaving out client response
Client response helps show engagement and readiness. A client who is surprised by the result, disagrees with it, expresses concern, or asks for help gives the clinician important treatment planning information.
Forgetting follow-up
If the result suggests further assessment or monitoring, document the next step. That may include continued discussion in therapy, referral to a substance use specialist, care coordination with consent, safety planning, or reassessment at a later date.
DAST documentation language you can adapt
Use these short examples when you need wording for common clinical situations. Edit each phrase so it accurately reflects the session.
Low concern example
“Client completed DAST screening as part of intake. Score fell in the low concern range per clinic scoring guide. Client denied current substance-related impairment and did not identify substance use as a treatment concern. Clinician reviewed results with client and will monitor if new concerns arise.”
Moderate concern example
“Client completed DAST screening and score fell in the moderate concern range per clinic scoring guide. Client reported increased cannabis use during periods of anxiety and sleep disruption. Clinician provided psychoeducation, explored motivation for change, and added substance use monitoring to treatment plan.”
Higher concern example
“Client completed DAST screening and score indicated elevated concern per clinic scoring guide. Client reported substance-related impairment affecting work attendance and relationships. Clinician reviewed results, assessed immediate safety concerns, discussed referral options, and will continue assessment during next session.”
How AutoNotes helps with DAST documentation
AutoNotes helps clinicians turn screening details into structured, editable progress note drafts. Instead of starting from a blank page after a full day of sessions, you can enter relevant session details, DAST score information, client response, interventions, and plan. AutoNotes then creates a draft you review, edit, and finalize.
For DAST-related documentation, AutoNotes can support a more consistent workflow by helping organize the same key elements each time: reason for screening, tool used, results, clinical interpretation, risk considerations, and next steps. This is different from using a generic writing tool because AutoNotes is built around behavioral health documentation and common clinical note structures.
Clinicians remain responsible for reviewing the note, correcting details, applying clinical judgment, and making sure the final record matches the session. AI can provide a faster starting point. It should not replace the clinician’s assessment or final review.
Where it fits in your documentation workflow
AutoNotes can be used after an intake, assessment, individual therapy session, or treatment planning session where DAST results are discussed. A clinician might enter: “DAST-10 completed, score 4, moderate concern per clinic guide, cannabis use nightly for sleep, client ambivalent but willing to track use, no current withdrawal concerns, plan to use MI and sleep hygiene.” From there, AutoNotes can draft a structured note section that the clinician edits before saving to the chart.
Start with the template, then make the note clinically specific
A DAST documentation template saves time because it keeps the essential fields in one place. The final note still needs your clinical specificity: what the client reported, how they responded, what risks were assessed, and what you plan to do next.
If DAST notes are one part of a larger documentation backlog, AutoNotes can help you create editable drafts for substance use screenings, intake sessions, progress notes, treatment plans, and other behavioral health documentation tasks.
Start your free trial to try AutoNotes with your own documentation workflow.
