Intake Screening Questions for Substance Use Disorder (SUD)

Intake Screening Questions for Substance Use Disorder (SUD)

Get patients connected to the proper care.
TIP: Hover over the fields for example question scripts!

Helpful Links
Staff Name

First NameLast Name
Staff Email
example@example.com
Patient Details
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Chief Complaint

Ask patient: "What are you seeking care for today?"
Details of Chief Complaint
Substance Use Questions
Knowledge Base
Common Medications Prescribed for Substance Use Disorder(s)
Has the patient ever been diagnosed with a Substance Use Disorder?
Is the patient currently taking any medication for Substance Use Disorder (SUD)?
SUD Medications

Other
Does the patient currently use any recreational drugs or substances that aren’t prescribed by a healthcare provider?
When was the last time the patient used any substances/alcohol?

MonthDayYear
Get an estimate of days or date
Recreational or Non-prescribed Drugs/Substances
List all substances the patient stated.
Is the patient willing to stop using the substance(s)? (As it may be difficult to treat any underlying problems)
Has the patient completed any treatment or rehab programs?
When was the the patient discharged from their last treatment/rehab?

MonthDayYear
Date
Is the patient involved in any support groups or recovery programs?
To select multiple fields, hold 'ctrl' on Windows or 'cmd' on Mac while you click!
Other Support Group
Assessment Status
IMPORTANT

Please include any notes regarding why they may need assessment and contact the BHL as soon as possible.

Notify the patient that this is a phone screening, appointments can be booked on the BHL's calendar here.
Potential Assessment Notes
LastUse
TreatmentDate
Current Date

MonthDayYear
Date
Should be Empty:

Intake Screening Questions for Substance Use Disorder (SUD)

Patient Details

Chief Complaint

Substance Use Questions