Addiction Medicine Intake Form
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Addiction Medicine Intake Form
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The Addiction Medicine Intake Form is designed for addiction medicine specialists and medication-assisted treatment programs, capturing the comprehensive substance use and recovery history needed for evidence-based treatment planning. This template collects patient demographics alongside a detailed substance use assessment including primary and secondary substances of use, route of administration, frequency and quantity, age of first use, duration of use, longest period of sobriety, most recent use, prior overdose events, and withdrawal history. The validated screening instruments embedded in the form help quantify substance use severity and guide level-of-care determination.
Built for addiction medicine practices, opioid treatment programs, buprenorphine and naltrexone prescribing clinics, residential and outpatient substance use treatment centers, and integrated primary care-addiction medicine programs, this form includes sections for prior treatment episodes (detoxification, residential, intensive outpatient, outpatient, sober living), medication-assisted treatment history (methadone, buprenorphine/naloxone, naltrexone, disulfiram, acamprosate), co-occurring mental health conditions (depression, anxiety, PTSD, bipolar disorder), legal and criminal justice involvement, social determinants of health (housing stability, employment, family support, childcare needs), recovery capital assessment, and readiness-for-change evaluation.
All fields are HIPAA-compliant and designed with trauma-informed, person-first language that reduces stigma and encourages honest disclosure. The form complies with 42 CFR Part 2 confidentiality requirements for substance use disorder patient records. Pre-visit completion allows the addiction medicine team to assess withdrawal risk, determine appropriate level of care, prepare medication-assisted treatment options, and develop a comprehensive treatment plan that addresses the biological, psychological, and social dimensions of addiction.
What's included
- Comprehensive substance use history and severity assessment
- Withdrawal risk screening and overdose history
- Medication-assisted treatment history and response
- Co-occurring mental health disorder screening
- Social determinants and recovery capital evaluation
- 42 CFR Part 2 compliant consent with e-signature
Who uses this template
- Addiction medicine and medication-assisted treatment programs
- Opioid treatment programs and buprenorphine clinics
- Residential and intensive outpatient substance use treatment
- Integrated primary care and addiction medicine practices
All form fields
16 fields across 3 pages. Customize any field after signing up.
How to use the Addiction Medicine Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Addiction Medicine Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Addiction Medicine Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 16 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Addiction Medicine Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Addiction Medicine Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Addiction Medicine Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Addiction Medicine Intake Form for your practice. Set up in minutes.
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