---
title: Substance Use Screening & Assessment Form Template with CAGE Questionnaire | Paperform
description: Confidential pre-visit substance use screening form for addiction medicine providers. Includes CAGE questionnaire, readiness to change assessment, and detox safety questions.
url: "https://paperform.co/templates/substance-use-screening-assessment-form"
type: static
generatedAt: "2026-03-28T00:45:18.002Z"
---

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### Substance Use Screening & Assessment Form Template

When it comes to addiction medicine and substance use treatment, the first consultation is critical—but before a patient even walks through the door, clinicians need to understand their history, current use patterns, readiness for change, and any immediate safety concerns. That's where a well-designed **substance use screening and assessment form** becomes an essential clinical tool.

This Paperform template is built specifically for addiction medicine providers, behavioral health clinics, counseling centers, and primary care practices that incorporate substance use screening into their intake workflow. It combines validated clinical instruments—including the widely used **CAGE questionnaire**—with readiness-to-change assessment and detox safety questions, all in a single, confidential, easy-to-complete form.

#### Why pre-visit substance use screening matters

Traditional paper-based intake forms often feel impersonal, are difficult to read, and can be lost or misfiled. Worse, they create delays: staff must manually review responses, flag concerns, and enter data into electronic health records before a provider can prepare for the appointment.

A digital pre-visit screening form streamlines this entire process. Patients complete the form on their own device—at home, in a waiting room, or wherever feels safe and private. Responses flow directly to your practice, giving clinicians time to review risk factors, tailor the first appointment, and prioritize urgent cases. For patients, the experience feels more respectful, less rushed, and genuinely confidential.

#### What makes this template effective for addiction medicine

This template isn't a generic health questionnaire—it's purpose-built for substance use assessment, incorporating evidence-based screening tools and safety protocols that addiction specialists rely on:

 - **CAGE Questionnaire:** A quick, validated four-question screen for alcohol use concerns (Cut down, Annoyed, Guilty, Eye-opener). It's non-judgmental, easy to understand, and clinically proven.
 - **Readiness to Change Assessment:** Based on the Stages of Change model, this section helps clinicians understand where a patient is in their journey—precontemplation, contemplation, preparation, action, or maintenance. This insight is crucial for treatment planning and motivational interviewing.
 - **Detox Safety Questions:** Screens for withdrawal risk, recent use patterns, past detox complications, co-occurring medical conditions, and current medications. These questions help identify patients who may need medically supervised withdrawal or urgent care.
 - **Substance Use History:** Captures which substances are being used, frequency, route of administration, and duration of use, giving providers a complete clinical picture.
 - **Mental Health & Support Screening:** Identifies co-occurring mental health conditions, trauma history, and available support systems—all critical factors in addiction treatment planning.

Conditional logic ensures that follow-up questions only appear when relevant, keeping the form concise for patients with minimal concerns while gathering detailed information when needed.

#### How Paperform fits into your addiction medicine workflow

Paperform makes it simple to deploy this form across your practice. You can embed it directly on your website's "New Patient" or "Get Help" page, include a link in appointment confirmation emails, or text it to patients after they schedule. The form is fully mobile-responsive, so patients can complete it on any device, and your branding—colors, fonts, logo—can be applied throughout for a seamless, professional experience.

Because this form handles sensitive health information, Paperform's infrastructure includes **SOC 2 Type II compliance, encrypted data transmission, and secure storage**, meeting the standards behavioral health practices expect. While Paperform is not HIPAA compliant, many practices use it successfully for pre-visit screening and non-protected health workflows, with appropriate safeguards and patient consent.

Responses are collected in real time and can be reviewed in Paperform's dashboard, exported to spreadsheets, or pushed to other tools via integrations. You can set up email notifications so clinical staff are alerted immediately when a high-risk submission comes through, or use **Stepper** (stepper.io) to automate more complex workflows—such as flagging urgent cases, assigning intake coordinators, updating your EHR, or scheduling follow-up calls.

#### Automate next steps with Stepper

Once a patient submits their screening form, Stepper can turn that data into action. For example, you might set up a workflow that:

 - Routes submissions with high CAGE scores or detox safety concerns to a clinical supervisor for immediate review.
 - Sends a personalized welcome email with resources based on the patient's readiness to change stage.
 - Logs the submission in your practice management system or CRM.
 - Schedules a callback from an intake coordinator within 24 hours.
 - Triggers different appointment types (urgent assessment vs. standard consultation) based on responses.

This automation reduces administrative burden, ensures no patient falls through the cracks, and lets your clinical team focus on care rather than paperwork.

#### Who benefits from this template

This form is designed for:

 - **Addiction medicine physicians** conducting outpatient evaluations
 - **Behavioral health clinics** offering substance use counseling and treatment
 - **Primary care practices** integrating SBIRT (Screening, Brief Intervention, and Referral to Treatment)
 - **Mental health counselors and therapists** working with clients who have co-occurring substance use concerns
 - **Community health centers** and harm reduction programs
 - **Employee assistance programs (EAPs)** offering confidential substance use support
 - **Telehealth providers** conducting remote addiction assessments

Whether you're a solo practitioner or part of a larger behavioral health organization, this template gives you a professional, evidence-based tool for gathering the information you need before the first appointment—improving care quality, patient safety, and operational efficiency.

#### Flexible, customizable, and ready to use

Every practice has its own protocols, and Paperform makes it easy to adapt this template to fit yours. Add or remove questions, adjust conditional logic, customize success messages with crisis hotline numbers or next-step instructions, and apply your clinic's branding throughout. You can also translate the form into other languages, add accessibility features, and embed consent language as needed.

With Paperform, you get the clinical rigor of a validated screening tool, the flexibility of a no-code form builder, and the reliability of a secure, SOC 2 compliant platform—trusted by over 500,000 teams worldwide.

Start screening smarter, supporting patients earlier, and building better treatment plans from the very first interaction.
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