MAT INITIAL PATIENT SCREENING

Patient Name

Date of Birth

Date

Address

Street Address Line 2

City State

Zip

Driver's License #

State

(Please provide for photocopy)

Height

Weight

Eye Color

Sex: M

F

Age

SS #

Phone

Marital Status

Ethnic Group

Prescription plan name (If applicable)

Card Number

(Please provide for photocopy)

Emergency Contact Name

Relationship

Address

Street Address Line 2

City State

Zip

Home Phone

Cell Phone

Work Phone

What is/was your primary drug of choice?

At what age did you first use?

Total years of opiate use

current cost per day

Date/time/drug last used

Date

# of times per day

What other drugs are you using?

Describe any previous substance abuse treatment

Do you have any outstanding warrants or legal problems? No Yes

Are your currently using any illegal substances?

What prescription medications are you currently taking?

For what purpose are you taking this medication?

What is the prescribing doctor's name and phone number?

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

This is a fill in the blanks field. Please add appropriate blank fields and text.

Signature

Clear

Date

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?

Anger Fear Sadness Shame Loneliness

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

Less than 25 25 50 75 100

3. When you experience the feeling you have named, do you think of

the present the past the future the present and the past the present and the future

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

feeing?

Ages 1 thru 5 Ages 3 thru 12 Ages 12 thru 20 Ages 20 thru 40 Ages 40 thru 80

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

Isolating, withdrawal, avoidance Acting, pretending, hiding feelings Verbal aggression or verbal abuse Physical aggression, physical abuse or violent action None of the above

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

Any form of self abuse A behavior that you believe to be dishonest

CompServ Health Resourees comprehensive

High-risk, life-threatening behaviors Destruction of objects, property, possessions None of the above

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

Pre-occupation with food re-occupation with money Pre-occupation with sex Pre-occupation with control None of the above

8. When you experience the feelings you have named, which of the following behaviors is most likely to occur?

Pre-occupation with suicide Pre-occupation with fire, explosives and weapons Pre-occupation with collecting, hiding or hoarding objects Pre-occupation with a person, celebrity, group, or place None of the above

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

Fantasizing about death Fantasizing about revenge or retaliation Fantasizing about sex or power Fantasizing about being another person or being in a different place or circumstances None of the above

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

Adjusting your behavior to become the center of attention Adjusting your behavior to avoid the attention of others Adjusting your behavior to please, manipulate or control others Adjusting your behavior to langer others None of the above

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

Attempts to "hide" in a specifiec place or places Attempts to "escape" or run from the situation Attempts to disguise yourself in some way Attempts to control a situation, a place or a group None of the above

12. If you have named a behavior or behaviors that have developed into a repetitive pattern in relation to the feeling you have named, can you remember the age in your life that the feeling/behavior combination or combinations first occurred?

Ages 1 thru 5 Ages 5 thru 12 Ages 12 thru 20 Ages 20 thru 40 Ages 40 thru 80

13. Was this pattern or patterns of behavior in existance

Prior to age 6 with no use of mood-altering substances Prior to age 12 with no use of mood- altering substances Prior to first use of mood-altering substances

Prior to addictive use of mood-altering substances Began or coincided with first use and onset of addiction to mood-altering substances

14. Have you ever attempted to

Change the behavior or behaviors Stop the behavior or behaviors Hide the behavior or bahaviors Limit the behavior or behaviors None of the above

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

15. Has the feeling/behavior combination or combinations you have named ever created.

A problem in your life Occasional problems in your life Many problems in your life Contiuous problem in your life

16. List below the physical symptoms that occur when the feeling/behavior combinations you have named happen to you. (For example shallow breathing, nausea, rapid heart beat, light neck and shoulders, headaches, etc).

Please place an "X" in the appropriate box

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

Y
N

2. Have you misused prescription drugs? Y

N Y Other

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

4. Can you get through the week without using drugs (other than those required for medical reasons)? Yo

No

-8-5

5. Are you always able to stop using drugs when you want to? YN

6. Do you misuse drugs on a continuous basis? YN

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

9. Do you ever feel bad about your drug misuse? YN

8. Have you had "blackouts" or "flashbacks" as a result of drug use? YoNo

9. Do you ever feel bad about your drug misuse? YN

11. Do your friends or relatives know or suspect you misuse drugs? YN 10. Does your spouse (or parents) ever complain about your involvement with drugs? YN

9. Do you ever feel bad about your drug misuse? YN

12. Has drug misuse ever created problems between you and your spouse? YNo

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

HAVE YOU EVER

14. Lost friends because of your use of drugs? YN

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

16. Been in trouble at work because of drug misuse? Y

N

17. Lost a job because of drug misuse? Y

N

No

18. Gotten into fights when under the influence of drugs? Y

Patient Name

Patient ID #

N

20. Been arrested for driving while under the influence of drugs? Y

No 19. Been arrested because of unusual behavior while under the influence of drugs?

21. Engaged in illegal activities to obtain drugs? Y

Y N 22. Been arrested for possession of illegal drugs?

23. Experienced withdrawal symptomes as a result of heavy drug intake? Y

Ni

23. Experienced withdrawal symptomes as a result of heavy drug intake? Y

25. Gone to anyone for help for a drug problem? Y

23. Experienced withdrawal symptomes as a result of heavy drug intake? Y

26. Been in the hospital for medical problems related to your drug use? YN

23. Experienced withdrawal symptomes as a result of heavy drug intake? Y

28. Been treated as an outpatient for problems related to drug dependence or misuse? YN

25. Gone to anyone for help for a drug problem? Y

N No 24. Had medical problems resulting from your drug use (memory loss, hepatitis, convulsions, or bleeding)? Y

26. Been in the hospital for medical problems related to your drug use? YN

No 27. Been involved in a treatment program specifically relataed to drug use? 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

Patient Name

Check

Male Female

Females complete as appropriate

To the best of my knowldege I am pregnant.

To the best of my knowledge I am not pregnant.

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

Initials

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.

Signature of Patient

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Today's Date

Date

Patient Name

Signature of Witness

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Today's Date

Date

INITIAL PATIENT SCREENING

THE GERWE ASSESSMENT FOR BEHAVORIAL HEALTH

THE GERWE ASSESSMENT FOR BEHAVORIAL HEALTH

DRUG ABUSE SCREENING TEST (DAST)