The Introductory Clinical Evaluation


Everyone has to start somewhere. For people entering residential treatment, there is a structured process for clinical evaluation. A credentialed clinical team will ask questions to learn about someone. A good team will strike a balance between both being compassionate and professional, while simultaneously answering some pressing questions which will be important for your care plan.

First Contact and Admissions

The first faces someone encounters at a treatment center are usually admissions staff and reception team. These are the people you or your family have spoken with on the phone. They’re involved planning for your admission to an addiction treatment program. Based on your initial phone call, they will have some understanding of your health needs even before greeting you face to face. They will welcome you, get your paperwork started and then connect you with a nurse who will help get you oriented to the residential treatment intake process.

Once you’ve been formally admitted and completed the necessary paperwork, you’re guided to the detox unit for assessment. A quality treatment facility will have a comfortable place where your medical care will begin. They will start an electronic medical record to begin gathering information for the clinical evaluation and implement treatment orders.

Basic Orientation

The first person to sit down with you in a private session will be a nurse. He or she will discuss physical and mental health issues with you and begin asking you questions about your history. Some people who enter treatment are still intoxicated on alcohol or drugs during their admission. It is important for a team to determine if you are coherent enough to be able to discuss your health. If this is not possible, the nurse will gather some objective information and may let you rest until you are more lucid.

It is surprisingly common for people with longstanding alcoholism to experience some memory loss or confusion as they grow older. During basic orientation, the nurse can determine what future evaluations to consider during treatment. It’s crucial to organize specialized care as early as possible.

For instance, a psychology team may conduct highly sophisticated cognitive assessments for certain people. These is a concern for older individuals about the development of dementia. A qualified treatment center will have clinicians who actively communicate with family and loved ones about more thorough evaluation for someone’s compromised cognitive abilities.


It is also common for people struggling with addiction to have malnourishment. We learn a lot about someone through their weight on admission. For those addicted to alcohol who are also very underweight, there may be concern that you are receiving almost sole nutrition from alcohol. These people require urgent supplementation of certain vitamins to stabilize some structures in their brain.

Low weight also can be useful screening for the presence of an eating disorder or major depression. Medical staff can use reliable assessments to ask more detailed questions during the clinical evaluation. This helps the treatment team establish a greater understanding of your health needs moving forward.

Blood Pressure

Elevated blood pressure is also very common with alcoholism. If a person has severely high pressure, we can use fast-acting medications to help decrease pressure. In some instances, a licensed, certified clinician will administer benzodiazepine medication if someone is experiencing severe alcohol withdrawal.

It is common for people to have baseline hypertension (high blood pressure). They typically take some medication to help with this issue from their primary care doctor. Qualified clinical facilities will monitor pressure trends over multiple days to determine if hypertension goes away after the person stops using drugs or alcohol. Some people are able to almost remove the hypertension diagnosis from their problem list through their sobriety. The person may not actually have primary hypertension – it was secondary to their alcoholism all along. Sobriety makes a huge improvement in physical health.

Blood Alcohol Content

We administer a urine drug screen and breathalyzer test upon entering treatment. This allows the treatment team to accurately determine the most recent substance used. Some people have extremely high blood alcohol content (BAC) on admission and seem to be walking and talking just fine. It is not uncommon to have someone blow a BAC level of 0.400. This is 5 times the legal DUI limit! It takes very significant tolerance for someone to be highly functional at this BAC.

If this happens, the medical team knows to be very cautious about a powerful withdrawal. Some people can start to experience shakiness and other alcohol withdrawal symptoms even before their BAC reaches zero.

Current Medications

The treatment team will review all current medications someone is taking prior to admission. We enter this information into a medical record. This becomes a template for making choices around medications used during treatment. Of note, some meds are more benign and will be easily maintained during someone’s course of care. These would include such meds as cholesterol medication, diabetes medication, or asthma medication. On the contrary, most controlled substances will be put on hold during the admission process.

Halted are all benzodiazepine and stimulant medications upon admission, no matter what prior diagnoses someone carries. It is common for some people to be upset about this. They will cite that a physician prescribed these medications. This isn’t a judgment of your character or you personally. It is important for an addiction treatment team to approach everyone’s care in a generally neutral way by starting from zero.

In a strictly medical capacity, It makes sense why we require a person to stop taking these potentially addicting meds no matter what someone may tell us. The course of treatment lasts many weeks and qualified staff will help you strategize your medication trajectories, but they need to start fresh in some areas. Medication approaches vary, depending upon the treatment center. You can discuss with the Admissions Team any questions or concerns you might have prior to entering treatment.


One of the primary goals of a high-quality treatment center is to establish good milestones in basic physical health. This includes ensuring that basic vaccinations are up to date. The most common of these would be a flu shot, depending on the time of year. Many people also get behind on receiving a tetanus booster or hepatitis B vaccination. There are a number of health interventions someone receives while in treatment, and vaccines are one of them.

Blood Testing

All people who enter treatment receive basic blood screening. The most common things tested and evaluated include:

  • Complete Blood Count
  • Metabolic Screen (sodium, potassium, liver function enzymes, etc.)
  • Thyroid Function
  • Testing for Sexually Transmitted Diseases (including Hepatitis C and HIV)
  • Sometimes the clinical team will order additional specialized tests for certain people. This is likely dependent on medications that the person takes or a prior health problem.
  • Basic Safety Screen

As the purpose of an initial clinical evaluation is to gather necessary information while helping someone feel comfortable and safe, a good treatment team will carefully ask questions about personal safety. This includes both potential thoughts of suicide or harm to others. We ask about home safety issues such as being a victim of domestic violence in your household.

These initial questions may seem highly personal and provocative. It is incredibly important that the treatment team ask them. It also demonstrates the culture at a high-quality facility. They are not afraid to discuss these things!

Many people every year are victims in their own home to violence or are at risk for suicide. It’s a primary function of the treatment center to help people heal from such suffering by starting the dialogue in a healthy, supportive environment. Remember that such information is confidential, aside from three important exceptions:

  • A threat of imminent danger to yourself
  • A threat of imminent danger to someone else
  • Instances of child abuse and neglect

All of these situations are considered safety emergencies and may require greater clinical attention. Your admission team will describe some of these boundaries and regulations when you admit. Policies regarding confidentiality versus mandatory disclosure are not specific to any facility. These are the laws for the State of Colorado and require specific disclosure to the appropriate state agency.

Other Questions

These themes are just some of the most common and useful points of clinical evaluation data gathered from all people who admit to a legitimate residential addiction treatment program. Additional questions involve your family history of addiction and mental illness, names of outside doctors and therapists, social and employment history, drug use history, allergies, surgical history, legal issues, and prior substance abuse treatment history.

All of this clinical evaluation information is used to build an overall picture of someone so as to guide their treatment in helpful ways. It is vital for a treatment team to sort through all of this information and use their clinical and scientific experience to make a difference in your health. We complete this entire process with a professional and caring approach which you deserve.

Read more CeDAR Education Articles about Treatment and Care.