Wyoming Professional Assistance Program Referral List Provider Questionnaire 2019
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Name *
Agency (if applicable)
Address *
City, State, Zip *
Phone *
Email *
Current Credentials/ License *
Number of years in practice *
Average wait time for an appointment from the time of initial contact
With appropriate, releases, are you willing to provide regular reports back to WPAP concerning client participation and engagement in treatment *
Do you provide Suboxone management?  
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Do you have formal addictions training *
Services provided *
What ASAM levels of care do you provide?
Please provide a brief description of your specialties, areas of advance training and experience
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