Wyoming Professional Assistance Program Referral List Provider Questionnaire 2019
Name *
Your answer
Agency (if applicable)
Your answer
Address *
Your answer
City, State, Zip *
Your answer
Phone *
Your answer
Email *
Your answer
Website
Your answer
Current Credentials/ License *
Your answer
Number of years in practice *
Your answer
Average wait time for an appointment from the time of initial contact
Your answer
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?
Do you have formal addictions training *
Services provided *
Required
What ASAM levels of care do you provide?
Your answer
Please provide a brief description of your specialties, areas of advance training and experience
Your answer
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