An alcohol evaluation, often formally known as a Substance Use Disorder assessment, is a structured process conducted by a qualified clinician to determine the nature and severity of an individual’s relationship with alcohol. The primary goal of this professional review is to establish a clear, objective clinical finding, especially when the evaluation is mandated for legal or occupational compliance. This comprehensive assessment provides the foundation for any necessary intervention or treatment plan.
Initial Assessment and Intake Procedures
The evaluation process begins with administrative and preliminary intake procedures, which establish the framework for the subsequent clinical review. The clinician first verifies the individual’s identity and the official referral source, whether it is a court order, a probation department, or an employer mandate. This stage involves a review of any associated records, such as arrest reports or employer documentation, to understand the context of the evaluation.
A detailed explanation of the limits of confidentiality is provided, which is important in mandated cases where the final report must be submitted to the referring agency. The individual also completes initial paperwork, including demographic information and a basic personal and medical history. Preliminary screening instruments may be used at this point, such as the Alcohol Use Disorders Identification Test (AUDIT) or the CAGE-AID, which quickly flag potential areas of concern.
The Clinical Interview and Standardized Instruments
The core of the evaluation involves a detailed clinical interview where the clinician gathers a comprehensive substance use history from the individual. Questions focus on the onset of alcohol use, the typical frequency and quantity of consumption, and any changes in drinking patterns over time. The interview specifically explores consequences related to use, covering areas such as legal issues, financial instability, occupational problems, and relational conflicts.
The clinician also investigates the presence of pharmacological effects, including increased tolerance and withdrawal symptoms upon cessation. Further inquiry includes screening for co-occurring mental health conditions, like anxiety or depression, which frequently present alongside problematic alcohol use. To ensure standardization and depth, comprehensive psychometric tools are integrated, such as the Addiction Severity Index (ASI) or the Substance Abuse Subtle Screening Inventory (SASSI), which provide objective data across multiple life domains.
Determining the Classification
The collected data from the interview and standardized instruments is then synthesized and analyzed against established clinical criteria to reach a formal classification. Clinicians utilize the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to determine if the pattern of alcohol use meets the threshold for an Alcohol Use Disorder (AUD). The DSM-5 outlines 11 specific criteria that measure impaired control, social impairment, risky use, and pharmacological effects.
A diagnosis of AUD requires that an individual meet at least two of these 11 criteria within a 12-month period. The severity of the disorder is then classified based on the number of criteria met: mild (two or three criteria), moderate (four or five criteria), or severe (six or more criteria). This categorical determination guides the subsequent development of a treatment plan tailored to the level of clinical need.
Required Recommendations and Follow-Up
The final step of the evaluation process involves formulating a set of required recommendations and an appropriate plan for follow-up care. The clinician compiles a formal written report detailing all findings, the specific clinical classification, and the rationale for the suggested course of action. Recommendations are structured based on the individual’s diagnosed severity and the American Society of Addiction Medicine (ASAM) criteria for levels of care.
For a mild classification, the recommendation might involve minimal intervention, such as an eight-hour Alcohol Drug Information School (ADIS) class or brief outpatient counseling. Moderate classifications often lead to a recommendation for traditional outpatient therapy or an Intensive Outpatient Program (IOP), which involves more frequent clinical contact. Individuals classified with a severe AUD are typically recommended for residential or inpatient treatment, which provides the highest level of structured support. Compliance monitoring is often included in the follow-up plan.