Patient presents with polysubstance dependence, exhibiting a problematic pattern of polysubstance use leading to clinically significant impairment or distress, as manifested by at least two of the following criteria within a 12-month period:  Impaired control over substance use (e.g., taking larger amounts or over a longer period than intended; persistent desire or unsuccessful efforts to cut down or control use; significant time spent obtaining, using, or recovering from substance use; craving).  Social impairment (e.g., failure to fulfill major role obligations at work, school, or home; continued substance use despite persistent or recurrent social or interpersonal problems caused or exacerbated by its effects; important social, occupational, or recreational activities given up or reduced because of substance use).  Risky use (e.g., recurrent substance use in situations in which it is physically hazardous; continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance).  Pharmacological criteria (e.g., tolerance, as defined by either a need for markedly increased amounts of the substance to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount; withdrawal, as manifested by either the characteristic withdrawal syndrome for the substance, or the same or a closely related substance is taken to relieve or avoid withdrawal symptoms).  Substances involved include (list substances).  Differential diagnoses considered include substance-induced disorders, mood disorders, anxiety disorders, and personality disorders.  Treatment plan includes referral to addiction specialist for further evaluation and management, consideration for medication-assisted treatment, individual therapy focusing on cognitive behavioral therapy and motivational interviewing techniques, and support groups. Patient education provided on risks associated with polysubstance use, relapse prevention strategies, and available community resources.  Follow-up scheduled in (timeframe) to monitor progress and adjust treatment plan as needed.  Current mental status examination reveals (patient's mental status, including mood, affect, thought processes, and judgment).