SUD form Brian Hyatt 6 years ago Substance Dependency Screening Your information will be encrypted, confidential, and HIPAA compliant once submitted Phone ** 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 {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…
