Substance Use Screening Form
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Hui Ho`ola O Na Nahulu O Hawai`i
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Burprenorphine Intake
Start completing your intake forms before your appointment!
All of our documents are HIPAA compliant and will be transmitted securely to our intake team.
Click the links below to begin.
Buprenorphine Agreement
Telehealth Consent
TB/Hepatitis/HIV Agreement
Authorization for Insurance
Laboratory Consent
Release of Information
Privacy Practices
Haumana Rights
Financial Responsibility
Consent to Treatment
Benzo/Opioid Policy
Name
** All information on this form will remain confidential , secure, and encrypted via HIPAA compliance
Title
Choose One
Mr.
Ms.
Mrs.
Prof.
Dr.
First Name
*
Last Name
*
Email Address
*
Contact Number
*
Alternate Contact Number
Do you have a place to live? If so, where?
*
Do you own your own car?
*
Employment Status
*
Unemployed, Full Time, Part Time etc
Which program are you interested in?
*
Methadone
Suboxone
Onyx
Please refer to the program page on our website for more information.
Do you have anxiety or depression?
Are you taking benzodiazepines? If so, which ones?
*
Date of Birth
*
Insurance Information
*
Name of insurance provider & policy #
Brief Summary of Usage History:
*
What are you taking, how often, for how long, and last use
How did you hear about us?
From a Friend
Internet
Referral from MD
Other
Information Summary
Company
** All information on this form will remain confidential , secure, and encrypted via HIPAA compliance
Title
Choose One
Mr.
Ms.
Mrs.
Prof.
Dr.
First Name
*
Last Name
*
Email Address
*
Contact Number
*
Alternate Contact Number
Do you have a place to live? If so, where?
*
Do you own your own car?
*
Employment Status
*
Unemployed, Full Time, Part Time etc
Which program are you interested in?
*
Methadone
Suboxone
Onyx
Please refer to the program page on our website for more information.
Do you have anxiety or depression?
Are you taking benzodiazepines? If so, which ones?
*
Date of Birth
*
Insurance Information
*
Name of insurance provider & policy #
Brief Summary of Usage History:
*
What are you taking, how often, for how long, and last use
How did you hear about us?
From a Friend
Internet
Referral from MD
Other
Information Summary
