SUD form – Kū Aloha Ola Mau

Substance Dependency Screening

Your information will be encrypted, confidential, and HIPAA compliant once submitted

Title

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?

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?