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Available Forms

SUBOXONE INTAKE QUESTIONNAIRE ONLY COMPLETE IF APPLICABLE

DRUG USE HISTORY

NOTE: this form is required for patients seeking detox or medially assisted treatment of opioids

INTAKE SCREENER

Methadone and Suboxone History

MENTAL HEALTH HISTORY

Please list any admissions to Rehab facilities, by Name/Location Dates or Year admitted<br/><br/>Write None if not applicable
Write None if not applicable

WARNING: YOU MUST CLICK "SUBMIT FORM" AND SEE A MESSAGE IN GREEN STATING "SUCCESSFULLY SUBMITTED" BEFORE GOING TO THE NEXT FORM OR THE ENTIRE FORM WILL BE LOST

* Required field