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Orlando - Pre-Screening Form
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Full Name
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Address
*
Your answer
Do you have a Florida ID?
*
Yes
No
How did you hear about us?
*
Your answer
What source of income do you have?
Choose
Employment
Medicaid/TANF
Medicare
Spouse
Parents
VA
Medicare and Medicaid
Are you able to attend the clinic daily?
*
Yes
No
What mode of transportation will you be using?
*
Your answer
FEMALES ONLY: Are you pregnant?
Yes
No
Clear selection
How many years have you been addicted to opiates?
Your answer
What drugs/prescriptions are you using?
Your answer
How much?
Your answer
When was your last use?
MM
/
DD
/
YYYY
Have you ever been in Methadone, Buprenorphine (Suboxone) or detox treatment?
Yes
No
Clear selection
Have you ever been in Pain Management treatment?
Yes
No
Clear selection
Have you ever been in Mental Health treatment?
Yes
No
Clear selection
Have you ever been in ANY KIND of treatment before?
Yes
No
Clear selection
Do you see a PCP or Psychiatrist?
Yes
No
Clear selection
Are you using a Benzodiazepine?
Yes
No
Clear selection
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