Forms

Adobe Reader is necessary to view and print forms

Forms You May Need for Your First Visit

C onsent for Medical Treatment- Required of all new patients.
Opiate Detoxification Form- Review this form if you seek detoxification from opiates, but not ongoing buprenorphine treatment.
Buprenorphine (Suboxone) Treatment Agreement- Review this form if are to receive buprenorphine (Suboxone) treatment for opiate dependence.

HIPAA Notice of Privacy- This is information provided to you as required by law. It applies to all of our patients. You do not have to bring a copy to the office.

Patient-Administered Psychiatric Screening Tests*

Bipolar Disorder Screening Form- Patient with Bipolar Disorder (Manic Depressive) are at increased risk for addiction.
Obsessive-Compulsive Disorder Screening Form- Many patients with addiction suffer in silence with this disorder, never telling their doctors out of embarrassment.
ADHD Screening Form- Patients with ADHD are at increased risk for addiction.
Depression Screening Form - Untreated depression often leads to drug addiction relapse. Depression also increases chronic pain.
Anxiety Screening Form- Anxiety can be treated with counseling and/or medication.
Post Traumatic Stress Disorder- (PTSD) Screening Form- Patients who suffered traumatic events in childhood or adulthood may suffer from this disorder; untreated it can add to emotional and physical suffering.
Alcoholism Screening Test- A brief test to let you know if you are likely a problem drinker.
S ubstance Abuse Screening Test- A test to help you determine if you might be an addict.
R eadiness to Change Questionn aire- Are you ready to change your life?

*These are "public domain" questionnaires available on the Internet