• INITIAL PATIENT SCREENING

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  • How did you first learn about Comp Serv Health Resources ? (If from a current patient, please provide that patient's name): 

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  • THE GERWE ASSESSMENT FOR BEHAVORIAL HEALTH

  • Please answer each question by placing an "X" in the appropriate box. 1. At present, during a 24 hour period of time, in a typical day, which of the following "feelings" seem to occur to you the most often?

  • 2. Approximately what percentage, or how much of the time, in a atypical day, do you feel the feeling you have named

  • 4.Can you remember your age when you first experienced the feeling you have named- - your first memory of this

  • When you experience the feeling you have named, which of the following behaviors is most likely to occur?

  • THE GERWE ASSESSMENT FOR BEHAVORIAL HEALTH

  • Please answer each question by placing an "X" in the appropriate box.

  • DRUG ABUSE SCREENING TEST (DAST)

  • Please place an "X" in the appropriate box

    1. Have you used drugs other than those required for medical reasons?

    • Y
    • N
  • 3. Do you misuse more than one drug at a time? YN

  • 7. Do you try to limit your drug uses to certain situations? Y

  • No 13. Has any family member ever sought help for problems related to your drug use? Y

  • 15. Neglected your family or missed work because of your use of drugs? Y

  • Scoring: Each positive response yields 1 point, except for questions 4, 5, and 7 which yield 1 point for a negative response

    A score greater than 5 requires further evaluatin for substance misuse problems.

    Skinner H.A. The Drug Abuse Screening Test, Addictive Behaivior 7(4): 363-371, 1982

  • Female Only: If I even think I am pregnant or might be pregnant or might become pregnant I will notify the staff of

  • Name of Practitioner Explaining Consent_Dr Latonya Lee Niang edD LCADC Clinical Director

  • I hereby authorize and give my voluntary consent to the above name Medical DirecotrDiana Berger, MD and/or any

    appropriately authorized assistants that he may select to administer or prescribe the drug Buprenorphine or Suboxone, as an element in the treatment for my dependence on narcotics (opiates-based) ddugs.,

    The procedures necessary to assess and/or treat my condition have been explained to me and I understand it will involve my taking daily doses of Buprenorphine or Suboxone, or other drugs, which will help me control my dependence on Heroin and/or other narcotic drugs.

  • It has been explained to me Buprenorphine or Suboxone is also a narcotic (opiate-based) drug, which can be harmful if taken without medical supervision. I further understand Buprenorphine or Suboxone is an opiate based (partial agonist) classified as an addictive medication and may, like other drugs used in medical practice, produce adverse results. The alternative methods of treatment, the possible risk involved, and the possibilities of complications have been explained to me, but I still desire to receive Buprenorphine or Suboxone due to the risk of my return to the use of opiates and /or opiods such as Heroin, Oxycontin, Morphine, or other such drugs of the narcotic (opiate) family.

    The goal of Buprenorphine or Suboxone treatment is total rehabilitation of the patient. Eventual tapering and withdrawal from the use of all drugs, including Buprenorphine or Suboxone, is an appropriate trreatment goal. I realize for some patients Buprenorphine or Suboxone treatment may continue for relatively long periods of time but the periodic consideration shall be given concerning my prospects for tapering and complete withdrawal from Buprenorphine or

    Iunderstand I may withdraw from the treatment program and discontinue the use of the drug at any time and I shall be

    afforded tapering and cessation under medical supervision.

    I agree that I shall inform any doctor who may treat me for any medical problem I am enrolled in a narcotic treatment program, since the use of other drugs in conjuction with Buprenorphine or Suboxone may cause me harm.

    Ialso understand during the course of treatment, certain conditions may make it necessary to use additional or different

    procedures than those explained to me. I understand these alternate procedures shall be used when the Program Medical Director's judgement is considered advisable.

    I certify that no guarantee or assurance has been made as to the results that may be obtained from Buprenorphine or Suboxone treatment. With full knowledge of the potential benefits and possible risks involved. I consent to Buprenorphine or Suboxone treatment, since I realize I would otherwise continue to be dependent upon and abuse narcotic drugs.

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