Buprenorphine Treatment Inquiry
In order to be placed on our waiting list for opioid dependence treatment with buprenorphine, please answer all questions below and submit this form. We will notify you if you are eligible for treatment and once we have an opening in the program. Thank you!
Date of Birth
Phone Number (please include area code)
Have you tried Buprenorphine before?
This includes in any formulation - Subutex, Suboxone films, Suboxone tablets, Zubsolv, Belbuca, Buprenex, and Butrans.
Yes, with a prescription
Yes, without a prescription
Select all substances you are taking currently, or have taken recently.
Include anything you are taking with or without a prescription
Amphetamines, such as Adderall, Ritalin, or Vyvanse
Benzodiazepines, such as Klonopin, Valium, Xanax, or Ativan
Opiates, such as Oxycodone, Hydrocodone, Codeine, Dilaudid, or Morphine
Please list any chronic health problems.
Are you currently being treated by another provider for substance abuse? If so, who is treating you?
How did you hear about our program?
How will you be paying for your treatment?
Please note that we are not in network with Kancare or Medicaid.
Private/Commercial Insurance (through an employer, exchange, partner, or parent)
Out of pocket (self-pay)
Do you have a Primary Care Physician?
Do you have a Counselor or Psychiatrist?
Send me a copy of my responses.
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This form was created inside of Healthy Strategies Family Doc, PA.