How to Create a Substance Use Intake Form for Substance Use Counseling (with Free Template)
This guide walks a substance use counselor or program through the ten substantive steps of building an intake form that meets 42 CFR Part 2 requirements (stricter than HIPAA), captures an ASAM Criteria assessment, addresses MAT informed consent when applicable, handles court-ordered treatment, discloses drug screening protocol, plans discharge, and produces a tamper-evident audit trail. Each step is one paragraph of working guidance. Estimated time end-to-end: 45 minutes from blank document to signed PDF when using an AI form builder. Formfy is the AI form builder substance use counselors and programs use to ship 42 CFR Part 2-aware ROI consent and intake with treatment-history capture in one workflow.
Before you start, gather six pieces of information: (1) the program license type and any CARF or Joint Commission accreditation, (2) the funding source mix (commercial, Medicaid, Medicare, SAMHSA Block Grant, self-pay), (3) the planned ASAM level of care, (4) the prescriber DEA registration if MAT is offered, (5) the drug screening protocol (panel, frequency, laboratory), and (6) the standard discharge step-down sequence. With those six inputs, the substantive drafting takes under 45 minutes. Without them, the 42 CFR Part 2 consent and ASAM assessment sections cannot be filled in.
Step 1: Disclose 42 CFR Part 2 (stricter than HIPAA)
Substance use disorder treatment records held by federally assisted programs are governed by 42 CFR Part 2, the federal Confidentiality of Substance Use Disorder Patient Records rule administered by SAMHSA. 42 CFR Part 2 is stricter than HIPAA: it generally requires patient written consent for nearly any disclosure of substance use treatment information, including disclosures that HIPAA would permit without authorization. The intake form must include a 42 CFR Part 2 notice that explains the rule, names the records that fall under Part 2, and includes a Part 2-compliant authorization to disclose for any planned releases (primary care provider, family, employer, court). The 2024 SAMHSA final rule aligned Part 2 more closely with HIPAA for treatment, payment, and healthcare operations but retained heightened protections for redisclosure and for criminal-justice and research uses.
Step 2: Conduct ASAM Levels of Care assessment
The American Society of Addiction Medicine (ASAM) Criteria provide the dominant U.S. framework for matching substance use disorder severity to appropriate treatment intensity. The 2023 update (ASAM Criteria, Fourth Edition) defines levels including 0.5 (early intervention), 1.0 (outpatient), 2.1 (intensive outpatient), 2.5 (partial hospitalization), 3.1 to 3.7 (residential and inpatient at varying intensities), and 4.0 (medically managed inpatient). The intake form should capture the six ASAM dimensions: acute intoxication or withdrawal potential, biomedical conditions, emotional and behavioral conditions, readiness to change, relapse and continued use potential, and recovery environment. The assessment determines the recommended level of care and is required by most commercial payors and state Medicaid programs for prior authorization of substance use treatment.
Step 3: Disclose DEA registration for medication-assisted treatment (MAT only)
Practitioners who prescribe buprenorphine, methadone, naltrexone, or other medications for opioid use disorder must hold an active DEA registration. The Mainstreaming Addiction Treatment (MAT) Act of 2022, included in the Consolidated Appropriations Act, eliminated the DATA-2000 X-waiver requirement effective January 2023, allowing any practitioner with a Schedule III DEA registration to prescribe buprenorphine for opioid use disorder without a separate waiver. Methadone for opioid use disorder remains restricted to SAMHSA-certified Opioid Treatment Programs under 42 CFR Part 8. The intake form should disclose the prescriber DEA registration number, the specific medications offered, the practitioner protocol for monitoring, and any program-level certifications (OTP, Office-Based Opioid Treatment, hub-and-spoke model).
Step 4: Address court-ordered treatment (consent vs participation)
Court-ordered substance use treatment is common (DUI, drug court, family court, probation conditions, child welfare). The intake form must distinguish between two concepts: legal compulsion to attend (the court order requires participation) and voluntary clinical consent (the patient still must provide informed consent for the specific treatment). 42 CFR Part 2 has special rules for criminal-justice referrals: a patient can sign a Part 2-compliant consent that allows the program to disclose attendance and progress to the referring court or probation officer, but the consent remains voluntary and revocable except under specific Part 2 criminal-justice provisions. The form should capture the court referral source, the consent for attendance reporting, and the patient understanding that they still retain treatment-decision rights.
Step 5: Disclose drug screening protocol
Most substance use programs include random or scheduled drug screening as part of treatment. The intake form should disclose the screening protocol: the type of testing (urine, oral fluid, hair, breath alcohol), the frequency (random, scheduled, observed, unobserved), the panel (5-panel, 10-panel, EtG for alcohol, prescription drug confirmation), the laboratory (CLIA-certified, in-house point-of-care), the consequence of positive results (clinical conversation, increased intensity, discharge consideration), the consequence of refused or missed screens, and the chain-of-custody procedure. Disclose how results are used: for clinical management only, or for reporting to court or probation under a 42 CFR Part 2 consent. Some states regulate the use of drug screening in treatment with specific consent requirements.
Step 6: Plan discharge with relapse and recovery resources
Discharge planning is required by most state licensing boards, CARF, the Joint Commission, and commercial payors. The intake form should disclose the discharge planning process: the criteria for successful completion, the criteria for unplanned discharge (continued use during higher levels of care, behavioral, financial), the relapse-prevention plan template, and the recovery support resources connected at discharge (Mutual Help Organizations such as AA, NA, SMART Recovery, recovery housing, peer recovery coaching, alumni programs). Document the standard step-down sequence (residential to PHP to IOP to outpatient to recovery monitoring). Capture patient consent for warm handoff to the next level of care, including any 42 CFR Part 2 release needed for that handoff. Disclose the practice readmission policy for relapse during outpatient stages.
Step 7: Address insurance and SAMHSA Block Grants
Substance use treatment is funded through commercial insurance, Medicaid, Medicare, federal grant funding (the SAMHSA Substance Use Prevention, Treatment, and Recovery Services Block Grant, formerly the Substance Abuse Prevention and Treatment Block Grant), state general funds, and patient self-pay. The intake form should capture the funding source, any state-specific Medicaid prior authorization requirements, and the patient acknowledgment of any out-of-pocket costs for non-covered services. Federal parity laws (the Mental Health Parity and Addiction Equity Act of 2008) require commercial group health plans to cover substance use treatment at parity with medical and surgical benefits. Programs receiving SAMHSA Block Grant funds have specific reporting and admission requirements; programs should disclose any priority-population obligations under Block Grant rules.
Step 8: Reference CARF accreditation (when applicable)
CARF International accredits behavioral health programs (the Joint Commission also accredits substance use treatment). When the program holds CARF accreditation in Substance Use Treatment, Opioid Treatment Program, or Behavioral Health, the intake form should reference the accreditation, the year of last survey, and the specific service tracks accredited. CARF accreditation drives specific intake form requirements: documentation of clinical justification for level of care, person-served involvement in treatment planning, cultural and linguistic considerations, and outcomes measurement. Non-accredited programs are not required to follow CARF standards but should still document the parallel standards their state licensing board imposes. Programs participating in third-party payor networks may need accreditation for in-network status.
Step 9: Address mandatory reporting overlap (child abuse and DUI history)
Substance use programs face two mandatory reporting overlaps with state law that interact with 42 CFR Part 2. First, state child abuse and neglect mandated-reporter statutes apply to substance use counselors as licensed mental health professionals. 42 CFR Part 2 has a specific carve-out at 42 CFR 2.12(c)(6) that permits disclosure for purposes of reporting child abuse or neglect under state law without patient consent. Second, some states require reporting of certain DUI history or impaired driving threats. Disclosure of impaired-driving threats is generally not exempt under Part 2 and requires either a Part 2-compliant consent or a court order issued under 42 CFR Part 2 subpart E. The intake form should disclose both mandatory reporting overlaps in plain language.
Step 10: Sign and store securely (e-signature and audit trail)
Use an e-signature workflow that produces a tamper-evident audit trail with timestamp, IP address, and consent to electronic records. The federal ESIGN Act and UETA (adopted in 49 states) make e-signed substance use intake forms legally equivalent to wet-ink signatures. 42 CFR Part 2 specifically allows electronic signatures on Part 2 consents (42 CFR 2.31). Store the signed packet (Part 2 notice and consent, ASAM assessment, drug screening protocol, discharge plan, MAT informed consent if applicable) in a system that meets HIPAA and Part 2 standards and that lets you retrieve files on 24-hour notice. Formfy, SimplePractice, and other behavioral health platforms support tamper-evident audit trails. Verify that the platform contractually agrees to Part 2 obligations (Part 2 has stricter business associate analogs than HIPAA).
Free template and downloadable PDF
Formfy ships a substance use counseling intake template that maps one-to-one to the ten steps in this guide. The template is editable in the AI form builder: describe the program type and the level of care and the builder returns a delivery-ready intake packet with the 42 CFR Part 2 consent block, the ASAM assessment fields, the MAT informed consent (when applicable), the drug screening disclosure, and the e-signature block. The PDF version is generated automatically when the patient signs and stored alongside the audit trail.
See also: /faq/substance-use-counseling-substance-use-intake for the FAQ companion hub covering 17 of the most common substance use intake questions.
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Start your free trialLast verified: 2026-04-25. This page is informational; it is not legal advice. Programs should review state licensing rules, the 42 CFR Part 2 final rule (2024 update), and accreditation-specific intake requirements with counsel.