SCREENING TOOL

1. Make sure the person on the phone is the person doing the
actual screening…Family members, friends, or other people
cannot complete a screening for someone else.
2. Get the patient’s name
a. Verify spelling - very important...DO NOT assume spelling of the patient’s name,
always ask the patient to spell their name to verify the correct spelling.
b. Look them up in Methasoft (Find Patient) to see if they are a former patient.
i. Do this whether they are a former patient or not; You cannot assume the
person on the phone is or isn’t a former patient based on their answer.
Always look up the names in Methsoft when doing a screening!
ii. If they are a former patient, write down their patient ID and ask them
about when they were last at the clinic like why they left the clinic.
iii. Check to see if they have a balance, check their discharge summary as
well before continuing with the screening.
iv. IF there is a balance the patient owes...Instruct the patient that we can
proceed with the screening, but he will have to pay the back balance
BEFORE he can be admitted. Depending on their response, you should
give the patient resources for other local clinics.
v. IF there is something in the discharge summary stating that he cannot be
admitted (ie. treatment team eval) then instruct the patient that his
admission will be brought to the treatment team for discussion and he will
be given a call back with the results of their decision. You should give the
patient resources for other local clinics.
vi. IF the patient was a recent discharge (under 30 days) you will need to
look at when the patient was discharged and inform him/her of that and
give them resources for other clinics in the area or invite him back to
come do a screening in 30 days (or however remaining days) and we can
do the intake at that point in time.
vii. IF there is no back balance or nothing in the discharge summary then
proceed with the screening.
3. Get the patient’s basic information such as: date of birth, phone
number (very important), gender, (if female ask if they are
pregnant - very important)
4. Drugs of choice:
a. Ask: What substances are you currently using?
i. You want the person to disclose all substances he/she is using NOT just
opiate use (Fentanyl, cocaine, Alcohol, etc…) To properly screen an
individual we need to know if they are actively using alcohol, benzos,
cocaine, opiates, meth, or any other illicit or licit substance.
ii. You also want to find out the frequency of their use, and how much they
are using (1gm daily, 1-2gms every 2-3 days, etc…)
iii. IMPORTANT - ask about any alcohol or benzo use
 1. If yes, get frequency and amount used. If Benzos are also used,
ask if they are prescribed and can verify their prescription.
iv. FYI - Alcohol and/or Illicit Benzo use automatically makes the person not
eligible for treatment. It is important that everyone getting screened is
assessed for alcohol/benzo use. Starting someone on Methadone if
they are using alcohol and/or benzos is extremely dangerous.
5. How long have you been addicted to opiates:
a. You are wanting to find out how long they have been actively addicted to and
actively using illicit opiates.
i. You want to ensure that they have at least 1 full year history of opiate
addiction.
ii. IF a person reports a 10 year history of opiate use, but have only recently
relapsed for the past 6 months…they qualify for treatment because they
have a long history of opiate abuse and it puts them at risk.
6. Date of last use:
a. Please try to be specific and ask the person when they last used as well as how
much they used.
b. Please do not just put a date here. Ask the person for the date, time, and
the amount used. You can also ask how it was used. Be as detailed as
possible.
7. Have you been administered Narcan in the last 14 days
a. Yes or No
8. Prior/Current Physical Problems
a. Please list all medical issues or problems the patient may have
b. Ask about any cardiac issues, diabetes, or other issues that may affect treatment.
c. Also ask if the patient has any medication allergies
d. This is where you would put if the person is pregnant. This is important because
they are at a higher risk .
9. Prior/Current mental health diagnosis
a. Please list all diagnosis the patient may have
b. Ask if the patient is in counseling for mental health
10. Current medications
a. Please list all current medications the patient may take that are prescribed
b. NON-prescribed medications should go in the “Drugs of Choice” area and should
be asked again in this section to ensure that the patient discloses any and all
illicit use.
11. Stable living environment
a. Yes or No
12. Support for recovery
a. Yes or No
13. Any other needs we can help you with?
 a. Mention housing, food, insurance or other benefits
14. How will you fund treatment
a. If the patient is SELF-PAY please let the patient know that he is responsible for
paying the daily fee of $19 and that if he does not pay they will not provide a
dose.
b. If the person has insurance get the insurance information from them such as the
type of insurance and member ID. Inform them that they will need to provide their
card upon admission to the clinic for insurance verification.
15. How did you learn about our treatment center?
a. Ask the patient about how he learned about the treatment center

Last steps:
1. Review the screening and verify if the person is eligible for intake or not eligible (You can
learn eligibility criteria from the P&P).
a. If the patient is not eligible then explain to the person why they are not eligible
and provide resources on other treatment facilities or recovery centers in the
area.
b. If the patient is eligible then look at the calendar and see when the next available
intake slot is and document it on the screening form.
2. Ask the patient if he is available to come in on that date for intake
a. Get verification that the person is able to come in for that date and time
b. Let him/her know that they must have a valid non-expired picture ID to be
admitted. If they do not have an ID they must be able to get one before being
admitted.
i. If their ID is expired it is not valid and they must get a new ID that is not
expired.
c. If the person is Self-Pay they also must have the money to pay for their dose
d. Inform the patient that intake times are typically about 2 hours but could be
longer depending on how many intakes there are.

Intake appointment Date/Time

1. Put in the date and time of the intake appointment
2. Make sure you also put it into the calendar as well
Program criteria:
1. Document that they have active opiate use; reporting last use from the date of last use.
2. If they do not meet criteria then write in “Patient does not meet criteria”
Rational:
1. Document data from “How long have you been addicted to opiates” (ie. Patient reports
over 1 year of active opiate use)
2. If they do not meet criteria briefly document why he/she does not meet criteria
Do not need Referral/or Services unless they do not meet criteria
Screening entered by:
1. Please make sure your name goes in here.