Suboxone & Vivitrol Intake Form

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Email *

DEMOGRAPHIC INFORMATION

Gender *

Female

Male

Last Name *

Suffix (i.e. Jr, Sr, III etc)

First Name *

Middle Name

Date of Birth *

YYYY

Age *

Marital Status *

Single

Married

Divorced

Legally Separated

Widowed

With Whom are you Currently Living? *

By Myself

Spouse and/or Children

With Significant Other

Other family

Friends

CONTACT INFORMATION

Email Address: (By supplying your email address, you are authorizing ICC to use your email address for communication including transmission of your personal and health related information.) *

Primary Phone Number *

Secondary Phone Number

Address 1 *

Address 2

City / Town *

Zipcode *

Are you currently homeless? *

Yes

Emergency Contact Name & Relationship *

Emergency Contact Phone Number *

INSURANCE INFORMATION

Primary Insurance *

Aetna

Blue Cross Blue Shield of Massachusetts

Blue Cross Blue Shield (Out-of-State)

Boston Medical Center (BMC)

Cigna

Commonwealth Care Alliance

Fallon Community Health Plan

GIC

Harvard Pilgrim Health Care

Health Plans Inc

MassHealth STANDARD AND CAREPLUS ONLY

Massachusetts Behavioral Health Partnership (MBHP)

Medicare

Network Health (Tufts Health Public Plans)

Tricare

Tufts Health Plan

United Healthcare

Other:

Primary Insurance ID *

Primary Insured Name / Subscriber Name *

Secondary Insurance

Secondary Insurance ID

SUBSTANCE USE INFORMATION

What is (or was) your "drug of choice"? *

Heroin

Opiates (Pain Medication)

Alcohol

Stimulants (Adderall, Ritalin)

Benzodiazepines (Xanax, Klonopin)

Other:

What is (or was) your amount of daily use of your drug of choice? *

What other drugs have you used regularly? (include all i.e. cocaine, alcohol, benzos etc) *

When was your last use of your drug of choice? *

Have you ever been in a drug treatment program? If so, please state where *

Have you ever been terminated or asked to leave such a program? *

Have you ever been a seller or distributor of drugs? *

Have you received any of the below Opioid dependence treatments before? *

Suboxone

Methadone

None of the Above

Other:

Required

Are you currently in Treatment? If so, which drug? (i.e. Methadone, Suboxone, Vivitrol etc) *

How frequently are you using? *

For how long have you been using *

How are you using (what route)? - List All

When is the last time you used? *

If currently on Methadone, please list current dosage, last date of filled script, and tapering schedule. Please note that due to adverse interactions, we will need verification of this information from your provider *

Please add any additional comments below

If you are being referred by Veterans, Inc. or Lakeside Recovery then you must complete our Supplemental Intake. You will see a link for the form after clicking submit below.

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