• New Patient Form

    Please complete this required onboarding form to move forward with your care. Once your form has been submitted, a member of our team will review it and contact you the same business day with the next steps. If you have any questions while completing the form, please call or text our office at 615-814-4797.

  • We are only serving patients that reside in Tennesee and are over the age of 18.

     

    Please do not refresh your screen while filling out the form - it will erase your progress.

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Format: (000) 000-0000.
  • Why are you seeking telehealth appointments?*

  • Opioid Use Questionnaire

  • 1. Take larger amounts or longer periods than intended.*
  • 2. Desire or unsuccessful effort to cut down opioid use.*
  • 3. A lot of time spent obtaining, using, or recovering.*
  • 4. Cravings (urge) to use.*
  • 5. Work, school, or home problems from use.*
  • 6. Continued use despite social or interpersonal problems from use.*
  • 7. Social, recreational, or work activities reduced from use.*
  • 8. Use in physically hazardous situations.*
  • 9. Use despite physical or psychological problems from use.*
  • 10. Need increased amount for intoxication or decreased effect with same amount.*
  • 11. Opioid withdrawal symptoms or take opioids to relieve or avoid withdrawal symptoms.*

  • Substances

  • What is the primary opioid you have been recently abusing?*
  • What drugs have you used in the past?*
  • Most common way you usually use opioids?*
  • How often do you use opioids?*
  • Tobacco:*
  • Alcohol*

  • Past Treatment

  • Have you been to treatment before?*
  • Have you ever been kicked out of a suboxone clinic?*

  • Stressors

  • What caused you to start on opioids originally?*

  • Background

  • Living arrangement:*
  • Is anyone in your current home actively using drugs?*
  • Do you have family members with a history of substance abuse?*
  • Do you have any current legal issues?*
  • Educational background:*
  • Marital Status:*
  • Do you have children?*
  • What is your employment status?*

  • Medical

  • Do you have any medication allergies?*
  • Are you currently taking suboxone?*
  • Past surgery?*
  • Are you pregnant?*
  • Do you have an OBGYN?*
  • Do you have a Primary Care Physician?*
  • Format: (000) 000-0000.
  • Do you authorize Crozier Recovery to communicate with your PCP?*
  • Should be Empty: