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Full Name

Phone Number

Email

What are your presenting problems?

Do you have any prior medical conditions?

Have any prior mental health conditions?

Any addiction or pain management challenges? Choose... Yes No

If yes, for how long? Choose... 30 Days or less 90 Days or less Greater than 90

Are you currently on Suboxone treatment? Choose... Yes No

If yes, for how long? Choose... 30 Days or less 90 Days or less Greater than 90

Prescribed other medication treatments? Choose... Yes No

If yes, for how long? Choose... 30 Days or less 90 Days or less Greater than 90

Where are you currently receiving treatment?

Why do you want to switch to our treatment?

Are you pregnant or trying to get pregnant? Choose... Yes No N/A

What insurance do you use?

How quickly are you looking to be seen?

How did you hear about us?

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