New Patient Application Name Name Phone Number Email What are your presenting problems? Do you have any prior medical conditions? Do you have any prior mental health conditions? Do you have any addiction or pain management challenges? Yes No If yes, for how long? 30 Days or less 90 Days or less Greater than 90 Are you currently on Suboxone treatment? Yes No If yes, for how long? 30 Days or less 90 Days or less Greater than 90 Are you currently prescribed other medication treatment? Yes No If yes, for how long? 30 Days or less 90 Days or less Greater than 90 Where are you currently receiving medical treatment? Why do you want to switch to our treatment program? Are you pregnant or trying to get pregnant? Yes No N/A What insurance do you use? How quickly are you looking to be seen by a medical professional? How did you hear about us?
