Suboxone Program PRE-ACCEPTANCE Application
This form is only for pre-acceptance into the Suboxone Program. This form in no way provides a relationship with yourself and anyone in the office of Belmont Psychiatric Services. Belmont Psychiatric Services may refuse your application. You will only be notified of your ACCEPTANCE.
Email *
First Name *
Middle Initial
Last Name *
Phone Number *
Phone Number above a Cell Phone or Home Phone
Clear selection
Can we leave a Voice Mail if nobody answers?
Clear selection
Address *
Date of Birth *
MM
/
DD
/
YYYY
Social Security Number *
Sex
Clear selection
FOR WOMEN ONLY - Are you pregnant?
Clear selection
For the Pregnancy question above, if your answer was - Yes or Not Sure - the application process ends here.
Referral Source (How did you find out about us)
Do you have Insurance to pay for your treatment? *
Insurance Name
Insurance ID number/Group number
Reason for seeking treatment now? *
Substance(s) currently used and route (oral, IV, nasal, etc): *
How often and how much do you use? *
How long have you been using? *
Approx. weekly cost of using? *
Has your drug use ever resulted in medical or legal problems? (if so - explain) *
Are there any CURRENT legal issues we should be aware of? (Probation, Parole, Court Proceedings) *
Have you ever been treated for substance dependence or misuse before (eg. detoxification program)? (if so - explain - dates and locations) *
Have you tried to quit on your own and if so, why did your attempt fail? *
Do you have any medical conditions (i.e heart murmur, asthma, depression, diabetes, hypertension, epilepsy, hepatitis, HIV/Aids, STD's or any other)? *
Are you currently taking any medications to treat the above mentioned condition(s)? *
Do you have any allergies? Please list them as well. *
Does any family member have a history of substance abuse? If so - Whom. *
Are you currently employed? If so, what do you do and how many hours per week? *
If you are not employed (and are not insured) how will you finance your treatment?
Please describe your current living arrangements and if there are children in the household what are their ages. *
Are there other addicts in the household? *
Do you have any other addictions such as Alcoholism, Gambling, Anorexia, Bulimia, Sex, Pornography? *
Will you have moral/emotional support throughout recovery, and from whom? *
We have a comprehensive Suboxone program, which requires you to be able to attend bi-weekly clinic/therapy sessions and the attendance of 4 community AA/NA meetings (Signature of chair required) PER WEEK!!! Will you be able to attend the mandatory clinics/meetings? *
is there any other information you wish to share?
Digital Signature below
Please understand your signature is only attesting to the statements above to be true. It does not hold you financially obligated nor does it obligate us to accept you.
SIGNATURE (please type your full name into the box below digitally signing this document) *
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