Hilo Clinic and Cultural Program
Medication Assisted Treatment
Hui Ho`ola O Na Nahulu O Hawai`i
Early Intervention Services
Buprenorphine Consent Forms
Please complete and submit all three forms.
Alcohol and Drug Abuse Division (ADAD) Form
Methadone Intake Packet
** All information on this form will remain confidential , secure, and encrypted via HIPAA compliance
Alternate Contact Number
Do you have a place to live? If so, where?
Do you own your own car?
Unemployed, Full Time, Part Time etc
Which program are you interested in?
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
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
Referral from MD