SUBOXONE
PROGRAM
PRE-SCREENING CHECKLIST
NAME: _______________________________ DATE:_________ TIME:______
If female, are you pregnant? YES NO
If “yes” we will then explain why pregnant women
are not eligible for admission to the Suboxone Program
Have you ever been in treatment at Walker Recovery Center?
YES NO
If yes, when?___________________ What was your ID#?________________
What is your birth date?_______________ (not eligible if under
18 years old)
What drugs have you used in last 24 hours?____________________________________
What is your favorite drug?_______________________________
If an opiate - “When did you first use __________ ?”
Do you inject drugs? YES NO
Have you used Suboxone before? YES NO
Do you have a current prescription for Suboxone?
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* What is your social security number? ________________________________
* Phone number where we can reach you? ________________________________
* You must bring a valid state driver license or non-driver
ID to the appointment.
* Cost is $100 cash (non-refundable) for initial appointment.
This includes clinical assessment, lab work, and nurse consult
and toxicology screen. There will be no medication until
the intake is completed at next visit.
* If you are eligible for the Suboxone Program, a second
appointment will be made in one week and will cost $150
cash. This second appointment will include physician examination,
counseling, nurse evaluation and medication. The first seven
days of medication will be included at no additional cost.
* Normally after the first week to ten days, the physician
will write you a prescription and it will be your responsibility
to have filled at your pharmacy. Once the physician writes
your prescription you will be billed $50 per week for clinical,
medical and administrative services to remain in the Suboxone
Program.
* We will give you directions to our clinic. You should
plan on at least two hours for screening.
* The second (intake) appointment will require four hours
to complete and will include initial medication with Suboxone.
* You will be given a time and date for screening.
If you are not eligible for Suboxone or appear inappropriate
for treatment, you will be referred to our Suboxone counselor
or Clinical supervisor for alternative treatment options.
_________________________ ______ _______________________
______
Staff Signature Date Clinical Reviewer Date
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For mor information on Suboxone program Click Here.
