suboxone program forms packet - oncall urgent care · 6 hatfield street, northampton, massachusetts...

6 Hatfield Street, Northampton, Massachusetts 01060

Suboxone Program

FORMS PACKET

413584SICK

Please fill this out and drop it off at 6 Hatfield

Street in Northampton. It will be reviewed by

our Suboxone Program Coordinator who will

call you to discuss scheduling an intake

appointment.

Before your intake appointment you must readthe ORIENTATION MANUAL!

The Basics

Name: Health Insurance Company:

Date of Birth: Policy Number:

OnCall Urgent Care Centers

6 Hatfield Street

Northampton, MA 01060

4135847425

Social Security Number:

Current Address:

Home Phone Number:

May we leave a message? Yes No

Cell Phone Number:

May we leave a message? Yes No

Health Provider Information

Name Address Phone

Primary Care Doctor:

Psychiatrist:

Therapist

(MANDATORY):

Other:

Personal Information

Emergency Contact Name:

Emergency Contact Phone Number:

Are they aware of your addiction? Yes No

Do you have any children of your own and/or living in your home ? Yes No


6 Hatfield Street


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If so, what are their ages?

How did you hear about our program?

Employer’s Name: Weekly Work Schedule:

How long employed?

Highest level of Education?


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Medication Use/Abuse History

Drug/Substance Examples/Street Names Usage

Barbiturates Amytal, Nembutal, Seconal,

Phenobarbital: barbs, reds, red birds,

phennies, tooies, yellows, yellow jackets

Currently using

Have in the past

Never used

Benzodiazepines Ativan, Halcion, Librium, Valium, Xanax:

benzos, candy, downers, sleeping pills,

tranks

Currently using

Have in the past

Never used

Flunitrazepam Rohypnol: date rape drug, forgetme pill,

Mexican Valium, R2, roofies, roofinol,

rope

Currently using

Have in the past

Never used

Methaqualone Quaalude, Sopor, Parest:

ludes, mandrex, quad, quay

Currently using

Have in the past

Never used

Ketamine Ketalar SV:

cat Valiums, K, Special K, vitamin K

Currently using

Have in the past

Never used

PCP type drugs Phencyclidine:

angel dust, boat, hog, love boat, peace

pill

Currently using

Have in the past

Never used

LSD acid, blotter, boomers, cubes, microdot,

yellow sunshines

Currently using

Have in the past

Never used


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Mescaline buttons, cactus, mesc, peyote Currently using

Have in the past

Never used

Psilocybin magic mushroom, purple passion,

shrooms

Currently using

Have in the past

Never used

Codeine Fiorinal with Codeine, Robitussin AC,

Tylenol with Codeine:

captain cody, schoolboy

Currently using

Have in the past

Never used

Fentanyl Actiq, Duragesic, Sublimaze:

Apache, China girl, China white, dance

fever, friend, goodfella, jackpot, murder

8, TNT

Currently using

Have in the past

Never used

Heroin brown sugar, dope, H, horse, junk, skag,

skunk, smack, white horse

Currently using

Have in the past

Never used

Morphine Roxanol, Duramorph:

M, Miss Emma, monkey, white stuff

Currently using

Have in the past

Never used

Opium laudanum, paregoric, big O, black stuff,

block, gum, hop

Currently using

Have in the past

Never used

Oxycodone Oxycontin, Percocet: Currently using


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oxy, O.C., killer, percs Have in the past

Never used

Amphetamine Dexedrine, Adderall:

bennies, black beauties, crosses, hearts,

LA turnaround, speed, truck drivers,

uppers

Currently using

Have in the past

Never used

Cocaine blow, bump, C, candy, Charlie, coke,

crack, flake, rock, snow, toot

Currently using

Have in the past

Never used

MDMA ecstasy, Adam, clarity, Eve, lover's speed,

peace, STP, X, XTC

Currently using

Have in the past

Never used

Methamphetamine meth, chalk, crank, crystal, fire, glass, go

fast, ice, speed

Currently using

Have in the past

Never used

Methylphenidate Ritalin:

JIF, MPH, Rball, Skippy, the smart drug,

vitamin R

Currently using

Have in the past

Never used

Marijuana weed, dope, grass, mary jane, pot Currently using

Have in the past

Never used

Nicotine cigarettes, cigars, smokeless tobacco,

snuff, spit tobacco, bidis, chew

Currently using

Have in the past


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Never used

Steroids Anadrol, Oxandrin, Durabolin, Depo

Testosterone, Equipoise:

roids, juice

Currently using

Have in the past

Never used

Dextromethorpha

m

Found in some cough and cold

medications; Robotripping, Robo, Triple

C

Currently using

Have in the past

Never used

Inhalants Solvents (paint thinners, gasoline, glues),

gases (butane, propane, aerosol

propellants, nitrous oxide):

Currently using

Have in the past

Never used

Typical Use/What you are Currently UsingSubstance Daily Usage Weekly Usage

Example: Heroin 2 bags 1012 bags

How much money do you spend per week on your habit?


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At what age did you begin using?

What did you start using? When did you start to use opiates?

Have you ever shared needles? Yes No

Have you ever overdosed? Yes No If yes, how many times?

Treatment HistoryDate Treatment Program For treatment of? Clean for?

July 1981 Detox—One Week Percocet/oxys 3 days clean

Do you attend AA or NA meetings?


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Yes If Yes, how many meetings a week?_________ Do you have a sponser?

_________

No

Have you ever been on Methadone Maintenance?

Yes, I am currently on Methadone Maintenance

Yes, I have been in the past (If yes, dates: ________________)

No, I have never been part of a Methadone program

If you are CURRENTLY on Methadone Maintenance:

o Program Location: _______________________________

o Counselor’s Name: _______________________________

o Current Dosage: _________________________________

o


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Have you ever been prescribed Suboxone before?

Yes, I am currently on another Suboxone program

Yes, I was prescribed Suboxone in the past (If yes, dates: ______________)

No, but I buy or have bought Suboxone on the street

No, I have never tried Suboxone before

If you are CURRENTLY prescribed Suboxone:

o Physician/Program Name :_______________________________

o Dates: __________________________

o Current Suboxone Dose: _____________________________

o Why are you leaving? __________________________

Please help us understand your legal situation

Have you ever been arrested because of drug use?

Yes If yes, please explain:

_______________________________________________

No What is the offense or offenses?


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Have you ever been incarcerated?

Yes If yes, how long incarcerated?

Are you on probation?

Yes If yes, when is it over?

No

Are you on parole?

Yes If yes, when is it over?

No

Are you facing potential jail time?

Yes If yes, how much?

No

Are you currently involved with DSS/DCF?

Yes

No If no, have you ever been?


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Please help us understand your social support network

What is your relationship status?

Single

Married

Long Term Relationship

Divorced

Other

Do you live alone?

Yes, I live alone

No, I live with __________________Do you have children?_____ How Many?

If you live with other people, are they aware of your substance abuse issues?

Yes

No

If you live with other people, do they also use?

Yes

No


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Does anyone in your family have a history of substance abuse?

Yes

No

Have you been a victim of abuse?

_ Yes

_ No

Please help us understand your transportation

How will you get to our program?

I have a car

I take public transportation

I live close enough to walk

I will get a ride from a friend or family member

Other ____________________

Our program requires random drug testing. In a random drug test, you will be called

and asked to report to the clinic within 24 hours. Will you be able to do this?

Yes

No


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Please help us understand your housing situation

Where do you live?

I have a permanent home

I am staying with family/friends

I am living in my car

I am living on the street

I am living in a shelter

I am in an alcohol/drug treatment program

I consider myself to homeless

Please help us understand more about your medical history

Medication Allergies:

Current Prescription

Medications:


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Surgical History:

Past Medical History (such

as diabetes, high blood

pressure, anxiety,

depression, bipolar,

schizophrenia, HIV/AIDS,

Hepatitis, PTSD, ADD,

panic attacks, OCD):

Treatment History for any

listed diagnosis?

Family Medical History

(such as diabetes, high

blood pressure, anxiety,

depression, heart disease)

FOR FEMALES ONLY: Are you currently pregnant?

Yes No If not, do you use

birth control? Yes No

What are your goals if you are accepted into the Suboxone program?

Is there anything else that you would like us to know about you?


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Patient Signature:

_______________________________________Date:________________

**Before your intake can be scheduled, you must have active insurance, a therapist

who you see at least once a week, and referrals from your primary care doctor if

required by your insurance. If you are unsure of whether you need referrals, do not

hesitate to ask someone at the front desk and they will be able to help you.

PATIENT CONTRACT BETWEEN ONCALL URGENT CARE CENTERS AND PATIENTSWHO ARE PRESCRIBED SUBOXONE

I will notify the OnCall Urgent Care of any change in my address or phone number. I understand that if I

do not do so, I may be liable to receive strikes.

I agree to keep, and be on time to, all of my appointments with the physician and/or physician assistantalong with the appointments I have scheduled with my substance abuse counselor.

I agree not to tamper with ANY urine screens and if I do so, I understand this will be grounds for

immediate for discharge from the Suboxone program with referral to a more extensive treatment

program.

I agree that I will not arrive at the office intoxicated or under the influence of drugs.


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I agree that the medication I receive is my responsibility and that I will keep it in a safe, secure place. I

agree that lost medication will not be replaced regardless of the reasons for such loss.

I agree that if my urine test for Suboxone is negative that I will be discharged from the Suboxone programand referred to a more extensive treatment program.

I agree that if I have three dilute urine tests that I will be subject to discharge from the program.

I agree to be courteous at all times while I am in the Urgent Care Centers and when speaking with staff onthe phone. I understand that those that accompany me to the center must also act in this fashion.

I agree to inform the Urgent Care Center of any new medications or medical conditions, and of any

adverse effects I experience from the medications that I take.

I agree to random pill counts

I agree to bring my Suboxone bottle to each visit, in the appropriate labeled container.

I will not allow anyone else to have, use, sell, or otherwise access my Suboxone.

I agree to cooperate with unannounced urine or serum toxicology screens as may be requested. I

understand that once I am called that I will have 24 hours to come to the clinic for my drug screen.

I agree that medication alone is not sufficient treatment for my disease, and I agree to participate incounseling.


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I understand that my medical records, course of treatment, and medical care will be kept at OnCall

Urgent Care Centers in a medical records system that is a confidential and locked. The notes will be

available to any healthcare professional involved in my care. For providers located outside of OnCall

Urgent Care Centers, I will be asked to sign consents so that my other health care providers can have

access to, and be involved in, my care.

I agree to receive my Suboxone from this program only.

I understand that the number of appointments that I will be required to keep includes (but is notnecessarily limited to):

Intake Appointment – Blood work, physical exam, urine drug test, meeting with

director of the program.

Induction Appointment Evaluation of withdrawal, receipt of prescription

Medication and Symptom Evaluation one to two days after Induction

Appointments weekly thereafter until I have been clean for TWELEVE weeks in a row,

after which I can move my appointments to every two weeks.

Biweekly appointments until I have had FOUR clean urines in a row, after which I can

move up to every three weeks.

Appointments every three weeks until I have had FOUR clean urines, after which I can

move up to monthly visits.

Monthly visits with decreasing Suboxone dosages until I feel like I am ready to stop

using Suboxone and have the ability to maintain sobriety on my own.


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I understand that the OnCall Urgent Care Center Suboxone Program will not release the results of my urinetoxicology screen to any other agency, program, or institution without a signed release. The purpose of thesetests are for my treatment at OnCall Urgent Care Centers only.

I understand the potential risks and l benefits of Suboxone and I am entering the Suboxone Program at

OnCall Urgent Care Centers voluntarily.

I understand that I can be discharged from the program at any time.

Before signing, please be aware that:

Patients have died from taking Suboxone

Patients have died because they mixed their Suboxone with other drugs like methadone and

valium

The longterm use of Suboxone and Subutex is controversial

Suboxone can become addictive

Some patients may suffer side effects such as constipation and dry mouth.

Suboxone can cause liver damage and therefore regular blood tests are required

I have read the Orientation Manual.

Patient Signature:__________________________________________

Patient Name:_____________________________________________

Date: ____________________________________________________

Provider Signature: ________________________________________

Provider Name:____________________________________________


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Confidentiality of Alcohol and Drug Dependence Patient Records

The confidentiality of alcohol and drug dependence patient records maintained by this practice/program is

protected by federal law and regulations. Generally, the practice/program may not say to a person outside the

practice/program that a patient attends the practice/program, or disclose any information identifying a patient

as being alcohol or drug dependent unless:

1. The patient consents in writing;

2. The disclosure is allowed by a court order, or

3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for

research, audit, or practice/program evaluation.

Violation of the federal law and regulations by a practice/program is a crime. Suspected violations may be

reported to appropriate authorities in accordance with federal regulations.

Federal law and regulations do not protect any information about a crime committed by a patient either at the

practice/program or against any person who works for the practice/program or about any threat to commit such

a crime.


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APPOINTED PHARMACY CONSENT

SUBOXONE® (buprenorphine HCl/naloxone HCl dihydrate) sublingual tabletSUBUTEX® (buprenorphine HCl) sublingual tablet

I (patient name)______________________________________________, do hereby authorize any employee of

the OnCall Urgent Care Centers located at 51 Locust Street, Northampton, Massachusetts 01060, to disclose my

treatment for opioid dependence to employees of the pharmacy specified below. Treatment disclosure most often

includes, but may not be limited to, discussing my medications with the pharmacist, and faxing/calling in my

buprenorphine prescriptions directly to the pharmacy. I also agree to allow the pharmacist to contact y physician

to discuss my treatment if necessary.

I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that

action has been taken in reliance on it. This consent will last while I am being treated for opioid dependence by

the physician specified above unless I withdraw my consent during treatment. This consent will expire 365 days

after I complete my treatment, unless the physician specified above is otherwise notified by me.

I understand that the records to be released may contain information pertaining to psychiatric treatment and/ortreatment for alcohol and/or drug dependence. These records may also contain confidential information aboutcommunicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by theCode of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from makingany further disclosures to third parties without the express written consent of the patient.

I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment

information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.

Pharmacy Name & Phone Number: Walgreens Pharmacies, 4135861190

Pharmacy Address: 70 Main St. Florence MA 01062


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Patient

Name:____________________________________________

Provider Signature:

________________________________________

Provider


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THERAPIST CONSENT TO RELEASE/RECEIVE CONFIDENTIAL INFORMATION

SUBOXONE® (buprenorphine HCl/naloxone HCl dihydrate) sublingual tabletSUBUTEX® (buprenorphine HCl) sublingual tablet

I (patient name)______________________________________________, do hereby authorize any of

the employees of the OnCall Urgent Care Center located at 51 Locust Street, Northampton,

Massachusetts 01060 to disclose or receive information pertaining to my treatment for opioid

dependence to or from my Therapist or Substance Abuse counselor: (counselor name)

_______________________________________________________.

I understand that I may withdraw this consent at any time, either verbally or in writing except to the

extent that action has been taken in reliance on it. This consent will last while I am being treated for

opioid dependence by the physician specified above unless I withdraw my consent during treatment.

This consent will expire 365 days after I complete my treatment, unless the physician specified above

is otherwise notified by me.

I understand that the records to be released may contain information pertaining to psychiatric treatmentand/or treatment for alcohol and/or drug dependence. These records may also contain confidentialinformation about communicable diseases including HIV (AIDS) or related illness. I understand that theserecords are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits therecipient of these records from making any further disclosures to third parties without the express writtenconsent of the patient.

I acknowledge that I have been notified of my rights pertaining to the confidentiality of mytreatment information/records under 42 CFR Part 2, and I further acknowledge that I understandthose rights.


Patient Name:_____________________________________________

Date: ____________________________________________________


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Planned Form of Therapy

I understand that I am required to participate in substance abuse counseling as part of myparticipation in Suboxone Program at OnCall Urgent Care Centers.

To meet this requirement I will be doing the following (please check all that apply):

Weekly Counseling with ___________________________(mandatory)

Weekly attendance at group therapy with ___________________(optional)

Weekly (or more frequently) AA/NA Meetings (optional)

Other________________________________________

Patient Signature: _____________________________________

Date: _______________________________

CONSENT FOR TREATMENT WITH BUPRENORPHINE AT ONCALL URGENT CARECENTERS

Buprenorphine is a FDA approved medication for treatment of people with opiate dependence.

Qualified physicians can treat up to 30 patients for opioid dependence with Buprenorphine for the first

year of practice and then can apply for another waiver to increase to 100 patients. Buprenorphine can

be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as

medically necessary, it is estimated that one will be on Buprenorphine for at least 6 months.

Buprenorphine treatment can result in physical dependence of an opioid. Withdrawal from

Buprenorphine is generally less intense than with heroin or methadone. If Buprenorphine is suddenly

discontinued, some patients have no withdrawal symptoms; others may have symptoms such as

muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opioid

withdrawal, Buprenorphine should be discontinued gradually over several weeks or more.


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If you are not in withdrawal, Buprenorphine may cause severe opioid withdrawal. If this is a concern of

yours please address the issue during your intake appointment with our Suboxone director.

It may take several days to get used to the transition from the opioid that had been taken and using

Buprenorphine. During this time any use of other opioids may cause an increase in symptoms. After

becoming stabilized on Buprenorphine, the use of other opioid will have less effect. Attempts to

override the Buprenorphine by taking more opioids could result in an opioid overdose.

You should not take any other medications without first discussing with your health care provider.

Combining Buprenorphine with alcohol or other medications may be hazardous. Combining

Buprenorphine with medications such as Klonopin, Valium, Haldol, Librium, Ativan has resulted in

deaths.

The form of Buprenorphine that you will be taking (Suboxone) is a combination of Buprenorphine with

a short acting opioid blocker (Naloxone). If the Suboxone tablet were dissolved and injected by

someone taking heroin or another strong opioid (i.e. Morphine), it would cause severe opioid

withdrawal.

Buprenorphine tablets must be held under the tongue until they completely dissolve, Buprenorphine

will not be absorbed from the stomach if it is swallowed.


Patient Name:_____________________________________________

Date: ____________________________________________________


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Provider Signature: ________________________________________

Provider Name:____________________________________________

PRIMARY CARE DOCTOR CONSENT TO RELEASE/RECEIVE CONFIDENTIAL

INFORMATION

I, ___________________________________________, authorize any employee of the OnCall Urgent

Care Center

Patient Name (Print)

at the above address to release or receive my treatment records to or from the following Primary Care

Doctor:

Primary Care Doctor’s Name: ______________________________________

Address:

______________________________________

Phone Number:

______________________________________

This information is for participation in the Suboxone Program.


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I understand that I may withdraw this consent at any time, either verbally or in writing except to the

extent that action has been taken in reliance on it. This consent will last while I am being treated for

opioid dependence by the provider specified above unless I withdraw my consent during treatment.

This consent will expire 365 days after I complete my treatment, unless the provider specified above is

otherwise notified by me.

I understand that the records to be released may contain information pertaining to psychiatric treatment

and/or treatment for alcohol and/or drug dependence. These records may also contain confidential

information about communicable diseases including HIV (AIDS) or related illnesses. I understand that

these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which

prohibits the recipient of these records from making any further disclosures to third parties without the

express written consent of the patient.

I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment

information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.


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Patient Name:_____________________________________________

Date: ____________________________________________________

Witness Signature: ________________________________________

Witness Name:____________________________________________

PATIENT CONTRACT BETWEEN ONCALL URGENT CARE CENTERS AND PATIENTS WHO AREPRESCRIBED SUBOXONE

Before signing, please be aware that:

Patients have died from taking Suboxone

Patients have died because they mixed their Suboxone with other drugs like methadone and

valium

The longterm use of Suboxone and Subutex is controversial

Suboxone can become addictive

Some patients will suffer side effects such as constipation and dry mouth

Suboxone can cause liver damage and therefore regular blood tests are required

I agree to keep, and be on time to, all of my appointments with the physician and his or her assistant

I agree not to tamper with urine screens and if I do so, this may be immediate grounds for discharge

from the Suboxone program.


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4135847425

I agree that I will not arrive at the office intoxicated or under the influence of drugs.

I agree that the medication I receive is my responsibility and that I will keep it in a safe, secure place. I

agree that lost medication will not be replaced regardless of the reasons for such loss.

I agree that if my urine test for Suboxone is negative that I will be discharged from the Suboxone program.

I agree that a dilute urine test is considered dirty.

I agree to receive my Suboxone from this program only.

I agree to be courteous at all times while I am in the Urgent Care Centers and when speaking with staff

on the phone. I understand that those who accompany me to the center must also act in this fashion.

I agree to inform the Urgent Care Center of any new medications or medical conditions, along with anyadverse effects I experience from the medications that I take.

I agree to bring my Suboxone bottle to each visit, in the appropriate labeled container.

I will not allow anyone else to have, use, sell, or otherwise access my Suboxone.

I agree to cooperate with unannounced urine or serum toxicology screens and pill counts as may be

requested. I understand that once I am called I will have 24 hours to come to the clinic for my drug

screen.


6 Hatfield Street


4135847425

I agree that medication alone is not sufficienttreatment for my disease, and I agree to participate incounseling.I understand that missed therapy appointments willresult is suspension.

I understand that my medical records, course of treatment, and medical care will be kept at OnCall

Urgent Care Centers in a medical records system that is a confidential, locked, filing system. The notes

will be available to any healthcare professional involved in my care. For providers located outside of

OnCall Urgent Care Centers, I will be asked to sign consents so that my other health care providers can

have access to, and be involved in, my care

I understand that the number of appointments that I will be required to keep includes (but is notnecessarily limited to):Intake Appointment Physical Exam

Induction Appointments on Days 12

Medication and Symptom Evaluation on Day 7 and weekly thereafter until I have 8 tox screens that are

“clean” in a row, after that I can move my appointments to every 2 weeks Moving beyond evaluations

at every two weeks will be determined by the treatment team (therapists and providers).

I understand that the OnCall Urgent Care Center Suboxone Program will not release the results of my urinetoxicology screen to any other agency, program, or institution without my consent

I understand the potential risks and l benefits of Suboxone and I am entering the Suboxone Program at

OnCall Urgent Care Centers voluntarily.


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I understand that I can be discharged from the program at any time.

I have read the Orientation Manual.

Please sign below:

____________________________________________________________________________________________

Patient Signature Patient name (Printed)

__________________________________________________________________________________

____

Provider Signature

Therapy Confirmation form

Instructions:

Patient fills out section one “Agree to participate in Substance abuse counseling

while in the Oncall Suboxone program.


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Patients Substance abuse counselor fills out section two. “Completed by Counselor”

Patient return form for Intake or next appointment.

1.

I_________________ Agree to participate in Substance abuse counseling

while in the Suboxone program. My substance abuse counselor

is______________. Phone number _______________.

2.

________________ Is engaged in Substance abuse counseling at

______________________ and has been attending since_________$$$$_.

I will inform you if he/she drops out of treatment.

Counselor signature___________________ Date_____________.

Contact person @clinic is Lynn MacDonald 4135847425 or email

[email protected]


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6 Hatfield Street


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suboxone program forms packet - oncall urgent care · 6 hatfield street, northampton, massachusetts...

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