Intake packet checklist for SUD and mental health programs

Intake coordinatorFirst call

Why the person is seeking care, symptoms, recent and last use, withdrawal history, medical conditions and medications, suicide and violence risk, living situation and insurance. Why: any positive safety answer goes to a licensed clinician the same day, and the screen documents why you admitted or referred the person, never because of a referral source or payment.

Intake coordinatorBefore day 1

Active coverage, benefits for this level of care, deductible, copay, out-of-pocket, whether prior authorization is needed and who gives it, the call reference number and the rep's name. Why: it's your evidence if a claim is denied, and it lets you tell the client in writing what they'll likely owe. Our sister site's VOB checklist lists the questions by level of care.

Billing or intakeWhen scheduled

Expected services and charges in writing. Why: the No Surprises Act requires it for uninsured and self-pay clients, and a client billed at least $400 more than the estimate can dispute the bill.

Client signsBefore or on day 1

Detox, hospital, residential, prescriber. Why: "outpatient was tried and failed" needs records, and so does a safe medication plan. Each release names the provider, the information and the purpose.

Front deskDay 1

Why: identity, the member ID and the payer phone numbers for the authorization, and the behavioral health company if the plan carves out those benefits.

Client and clinician sign

The services, benefits and risks, other options, the limits of confidentiality (danger to self or others, abuse reporting, court orders, emergencies), how to reach the program and what to do in a crisis (911, or call or text 988), the right to refuse or stop, and, for programs, attendance and the possibility that the health plan reviews progress. Why: it's informed consent, and the first thing a chart auditor looks for: signed before the first service.

Client acknowledges

How information is used and shared, the client's rights (copies, corrections, a list of disclosures, restrictions, private contact), and how to complain to the program and to HHS. SUD programs add the Part 2 section. Why: HIPAA requires the notice; if the client won't sign the acknowledgment, record the reason and what you tried.

Client signsBefore any record is shared

Written consent to disclose substance use disorder records, including to the health plan for payment. Since the 2024 rule, one consent can cover all future treatment, payment and health care operations. Why: without it you can't send a claim or an authorization request that identifies the client as an SUD patient. More in Part 2: the consent that's different.

Client or responsible party signs

What insurance covers and what the client owes, copays, self-pay rates, payment plans, statements and collections, and the client's request that the plan pay the program directly. For programs: plans approve days in advance, and the client is told promptly if days are denied. Why: it prevents billing disputes and authorizes you to bill the plan; for SUD care, information still goes to the plan only under the Part 2 consent.

Client signs receipt

Dignity and respect, freedom from abuse, neglect and retaliation, privacy, taking part in treatment planning, refusing treatment, seeing the record, interpreters and accommodations, and knowing why a discharge is recommended. Why: licensed Texas chemical dependency programs must give and post the client rights listed in 26 TAC chapter 564, in the rule's wording where it gives one; accreditors check them too.

Client signs receipt

How to complain (in person, by phone, in writing or anonymously), who answers and by when, how to appeal, and the outside options: the clinician's licensing board, the state agency that licenses the program, the health plan, the accreditor and, for privacy, HHS's Office for Civil Rights. Why: a client who can't find the process can't use it, and surveyors ask clients whether they know it.

Client signs

Attendance for the level of care, keeping what other group members share confidential, no weapons, alcohol or drugs on site, and how changes in level of care or discharge are decided. Why: it sets expectations a discharge decision can rely on later.

Client signs

Often a section of the consent to treatment: testing is part of treatment, results guide care rather than punish, and results are protected like the rest of the record. Why: consent before collection, and a policy that matches it (instant cups need a CLIA certificate of waiver).

Client signs

The client's location at each session, technology limits and privacy, the emergency plan, and the right to in-person care. Why: the clinician must know where the client is to act in an emergency and to stay within their license.

Client signs; staff witness

Family, referral source, court or probation, primary care, aftercare provider. Each names the recipient, what may be shared, the purpose, an end date or event, and the right to revoke. Psychotherapy notes and SUD counseling notes need their own separate authorization. Why: every call to someone outside the program needs one first, and auditors check each contact in the chart against a release.

Client signs

Who to call in an emergency (with consent to contact them), and whether the client accepts appointment reminders by text or email, knowing they aren't fully secure. Why: a reminder that reveals treatment to the wrong person is a privacy breach.

Intake coordinator or counselor

The tour and the emergency exits and evacuation route; the schedule and what each group is for; the program rules; where rights and the grievance process are posted; confidentiality in groups; how to reach staff, and after hours (988 and 911); drug testing; medications on site; that the health plan reviews progress to approve more days; and what discharge and step-down look like. Why: it proves the rights and rules were explained, not just handed over.

Licensed clinicianDay 1

Why: safety first; a positive screen leads to a safety plan, a higher level of care or a call to 988 or 911, documented the same day.

Primary counselorWithin your policy's days

Why: it shows this level is the least intensive one where the client can be treated safely, which is what the plan's reviewer reads (The ASAM Criteria). Texas: 26 TAC 564 sets assessment timelines for licensed chemical dependency programs; put the rule's timeframe in your policy.

Counselor and clientWithin your policy's days

Why: every group and individual note links back to a plan goal; without a plan, notes can't show why the client was there.

Prescriber

Why: co-occurring conditions and medications for opioid or alcohol use disorder are part of the plan; taking a prescribed medication is never by itself a reason to refuse admission.

CounselorAt intake, then on a schedule

Why: Joint Commission expects a standard measure repeated over time, and the trend is your best continued-stay evidence.

Who may consent for a minor or another adult, and the papers that show it (custody order, guardianship, power of attorney). Check your state's rules on when minors may consent to their own care.

And recorded when used, so consent is informed for everyone.

Where clients can see them, with how to complain to the state licensing agency, and the privacy notice on your website.

"42 CFR part 2 prohibits unauthorized use or disclosure of these records," with a record of each disclosure in the chart.

Dated, approved by the owner or governing body, with old versions kept. The 2024 Part 2 rule, for example, required updated notices and consents by February 16, 2026.