Potential Client/Resident Intake Form

NOTE ABOUT MAINTENANCE MEDS FOR OPIOID ADDICTIONS

We allow Suboxone if you agree to an exit plan with your health provider, or with a referral from us.
We also permit Vivitrol injections. No Methadone.

This form is used to collect information for internal purposes only. The information you provide will remain confidential and privileged. Please answer all questions fully and accurately to the best of your knowledge.