What substance use intake software needs to collect, and when
Intake in substance use treatment carries more weight than in almost any other setting. The patient is often ambivalent, the window for engagement is hours rather than weeks, and the same visit has to produce a level-of-care decision, a risk picture and a documentation trail. Intake software that tries to collect everything at once loses people at the front door. The sequence below splits intake into a short screen, a severity screen and a structured assessment, and uses repeat measurement rather than one long form.
Stage intake instead of front-loading it
SBIRT is the framework most programs already reference: a brief screen for everyone, a short motivational conversation for positives, and a warm referral for likely dependence. Intake software should make that sequence the default path, with the longer assessment reserved for people entering treatment rather than everyone who walks in.
| Stage | Instrument | Items | Time | Cut-off |
|---|---|---|---|---|
| Prescreen | CAGE-AID | 4 | 1-2 min | 1+ yes positive; 2+ strongly suggests a disorder |
| Alcohol screen | AUDIT-C | 3 | 1 min | 4+ men, 3+ women |
| Drug screen | DAST-10 | 10 | 2-3 min | 3-5 moderate, 6-8 substantial, 9-10 severe |
| All substances | WHO ASSIST | 8 per substance | 5-10 min | 4-26 moderate, 27+ high risk |
| Full assessment | ASI-Lite | 111 | 30-45 min | Composite score per life domain |
| Co-occurring screen | PHQ-9 + GAD-7 + PCL-5 | 36 | 8-10 min | Standard published bands |
| Ongoing monitoring | BAM | 17 | 3-5 min | Risk and protective subscale trends |
Screen for co-occurring conditions at intake, not later
Over half of substance use presentations carry a co-occurring psychiatric condition, and untreated co-occurrence is among the strongest predictors of early return to use. An intake that captures DAST-10 without PHQ-9, GAD-7 and a trauma screen produces a treatment plan that will need rewriting within a fortnight.
Suicidality has to be handled at the moment of answering, not in a nightly report. Endorsement of the PHQ-9 safety item, or of a crisis item on any instrument, raises an immediate tier-one alert to the treating clinician, and the patient is shown the 988 Suicide & Crisis Lifeline on screen.
What intake software should produce by the end of the visit
- A severity picture per substance, with the scoring shown rather than a bare total.
- A co-occurring mental health baseline that can be re-measured on a schedule.
- A documented risk decision, including withdrawal risk and any naloxone discussion where opioids are involved.
- A baseline that later admissions and discharges can be compared against.
- An audit trail: what was sent, when it was completed, who read the result.
Intake is the first point on a curve, not a one-off form
The reason intake matters commercially is that every later number depends on it. Length of stay, early-dropout and AMA rates, 30-day follow-up and improvement percentages are all measured from the intake baseline. If intake scores are captured on paper and typed in a week later, none of those measures can be produced reliably.
TouchpointHQ keeps intake, mid-treatment and follow-up measurement in one timeline per patient, plotted against days from treatment start, so the same record answers both the clinical question and the reporting one.
The workflow end to end
Send the prescreen before the visit
An emailed link to CAGE-AID or AUDIT-C means the conversation starts from data instead of a blank form.
Add depth only for positives
DAST-10 or ASSIST follows a positive prescreen; ASI-Lite is reserved for admission.
Capture the co-occurring baseline
PHQ-9, GAD-7 and PCL-5 at intake give you something to re-measure against.
Escalate risk immediately
Crisis items alert the clinician the same day and show the patient the 988 Lifeline.
Schedule the follow-ups now
BAM every 30 days, plus the 48-hour, 7-day, 14-day and 30-day AMA cadence where relevant.
Codes commonly used for screening and brief intervention
99408 / 99409
Alcohol and/or substance abuse structured screening and brief intervention (SBI), 15-30 min and over 30 min.
G0396 / G0397
Alcohol and/or substance misuse structured assessment and brief intervention, Medicare equivalents.
96160 / 96161
Administration of a patient-focused or caregiver-focused health risk assessment instrument with scoring and documentation.
Coverage and documentation requirements vary by payer and state. Confirm with your payer before billing.
Related tools and guides
Frequently asked questions
What does substance use intake software do?
It sequences the intake questionnaires — a brief screen, a severity screen, co-occurring mental health screens and, for admissions, a structured assessment — delivers them to the patient by email, scores them automatically, flags risk answers immediately, and stores the result as the baseline every later outcome is measured against.
Which instruments should be part of an intake?
A prescreen (CAGE-AID or AUDIT-C), a severity screen (DAST-10 or the WHO ASSIST), and co-occurring screens (PHQ-9, GAD-7 and a trauma measure such as the PCL-5). ASI-Lite is used for treatment planning at admission rather than for everyone screened.
Can patients complete intake questionnaires before arriving?
Yes. Each patient receives a single-use emailed link that opens on their phone, with no app and no password. Unfinished forms resume where they stopped, and links expire on a date you set.
How are suicidality answers handled?
Crisis items are defined per instrument rather than guessed. Endorsement raises a tier-one alert to the treating clinician the same day, and the patient is shown the 988 Suicide & Crisis Lifeline on screen.
Does it replace our EHR?
No. It runs the measurement and outreach that EHRs generally do not automate, and pushes the resulting scores, alerts and rollups back into the chart through an API, webhooks or a scheduled file exchange.
References
- SAMHSA. Screening, Brief Intervention, and Referral to Treatment (SBIRT) guidance.
- Skinner HA. The Drug Abuse Screening Test. Addictive Behaviors, 1982.
- Bush K, et al. The AUDIT alcohol consumption questions (AUDIT-C). Arch Intern Med, 1998.
- Cacciola JS, et al. Development and initial evaluation of the Brief Addiction Monitor (BAM). J Subst Abuse Treat, 2013.
Educational information for clinicians. Screening results are not a diagnosis and do not replace clinical assessment. If you or someone you know is in crisis, call or text 988 for the Suicide & Crisis Lifeline.