DA Form 4465: Patient Intake/Screening Record (PIR) PDF – DA Form 4465, officially titled Patient Intake/Screening Record (PIR), is a U.S. Army form used primarily within the Army Substance Abuse Program (ASAP). It standardizes the collection of patient information during initial intake and screening for substance use issues.
The form supports the identification, assessment, referral, and enrollment decisions for active duty service members, Department of the Army civilians, and eligible family members dealing with alcohol or drug-related concerns. It is referenced in DA PAM 600-85 and AR 600-85.
Download the Official DA Form 4465 PDF
You can download the current official version directly from the U.S. Army Publishing Directorate:
DA Form 4465 PDF
Purpose of DA Form 4465 in the Army Substance Abuse Program
The primary purpose of the PIR is to document essential identifying information, eligibility details, screening outcomes, physician diagnoses (where applicable), and enrollment decisions for substance abuse prevention, counseling, or treatment services.
It helps ASAP counselors, clinical directors, and commanders make informed decisions about enrollment in community counseling centers, adolescent services, or civilian facilities. The form ensures compliance with privacy regulations while facilitating coordinated care.
Key Sections of DA Form 4465 (Patient Intake/Screening Record)
Section I – Identification
This section captures basic patient data, including:
- Date enrolled/screened (YYYYMMDD)
- Patient identification (name, rank, SSN, etc.)
- Date of birth
- Service area code and community counseling center name
- Department (Army, Air Force, etc.)
- Eligibility category (Active Duty, Civilian, Family Member, etc.)
- Case finding method (e.g., Commander Referral, Self-Referral, DWI/DUI, etc.)
Section II – Military Personnel and Civilian Employee Data
This includes component, grade, sex, consent to release information to supervisor (for civilians), and whether the position is a mandatory testing position.
Section III – Drug/Alcohol Diagnosis
Completed by physicians, this section includes primary and other diagnoses with codes, physician signature, and enrollment facility recommendations.
Section IV – Enrollment Decision
Records the final decision (Enroll or Do Not Enroll), basis for the decision, enrollment facility, and reasons for non-enrollment if applicable. It requires signatures from the counselor and clinical director.
Privacy Act Statement and Confidentiality
The form includes a detailed Privacy Act Statement citing authorities such as 5 USC 301, 10 USC 3013, 42 USC 290dd, AR 600-85, and EO 9397. Information is used for treatment, counseling, and rehabilitation.
Disclosure is limited (e.g., to VA health care, medical emergencies, court orders, or authorized research). Provision is mandatory for active duty members (with potential UCMJ implications for non-compliance) and voluntary for civilians, though incomplete information may limit treatment processing.
Records are protected under confidentiality laws for substance abuse treatment.
Who Uses DA Form 4465 and When?
- ASAP Counselors and Clinicians: During initial screenings and assessments.
- Commanders and Supervisors: For referrals and enrollment decisions.
- Physicians: For formal diagnoses.
- Civilian Employee Assistance Program Coordinators (EAPCs): For civilian screenings and referrals.
It is typically completed when a service member or civilian is referred due to positive drug tests, alcohol incidents, commander directives, self-referrals, or other identification methods.
How to Fill Out DA Form 4465?
- Complete Section I with accurate patient identifiers and referral details.
- Fill Section II for military/civilian specifics and consent.
- Physicians complete Section III for diagnoses.
- Document the enrollment decision in Section IV with required signatures.
Always use the official fillable PDF when possible and ensure compliance with current AR 600-85 guidance. Consult your local ASAP or SUDCC staff for specific installation procedures.
Related Forms and Resources
- DA Form 4466 (Patient Progress Report)
- DA Form 8003 (ASAP Enrollment)
- DA Form 5017 (Civilian Consent Statement)
- AR 600-85 (The Army Substance Abuse Program)
- DA PAM 600-85 (guidance on form completion)
For the most current policies, refer to official Army publications on armypubs.army.mil.
Importance of Accurate Completion for Service Members and Civilians
Proper use of DA Form 4465 supports early intervention, reduces stigma around seeking help, ensures continuity of care, and helps maintain force readiness. Accurate documentation protects privacy while enabling effective rehabilitation and return to duty.
If you are a Soldier, DA Civilian, or family member needing assistance, contact your installation ASAP or Behavioral Health services promptly. Self-referral is encouraged and confidential to the extent permitted by regulation.