COMPASS RECOVERY
OPIOID REHABILITATION PROGRAM
QUESTIONAIRE FOR PROSPECTIVE OPIOID REHABILITATION
Name _____________________________________________ Birthdate _____ /_____ /________
Home phone ( ) ______ - ________ Cell phone ( ) ______ - ________
Please answer the following questions which will help us to design your plan of treatment:
Why are you interested in our rehabilitation program? ______________________________________________
__________________________________________________________________________________________
Have you been previously treated with Suboxone? □ yes □ no
When/Where was your last treatment? ____________________________________
How long were you treated? ____________________________________________
Is there any problem that makes it difficult for you to give routine urine specimens? □ yes □ no
If yes, please explain ________________________________________________________________________
History:
Please list all drugs you have used in the past: ____________________________________________________
__________________________________________________________________________________________
Have you ever injected IV drugs?
If yes, have you ever shared needles?
Have you ever been tested for HIV/AIDS?
□ yes □ no
□ yes □ no
□ yes □ no
If yes, what was the date of your last test? ____________
Have you ever been tested for Hepatitis B or C?
□ yes □ no
If yes, are you being treated for Hepatitis B or C?
□ yes □ no
Result? Neg Pos
Have you ever been treated for substance dependence or misuse (e.g., detoxification program)? □ yes □ no
If yes, please describe setting, length ____________________________________________________________
__________________________________________________________________________________________
Have you ever overdosed on alcohol or drugs? □ yes □ no
Have you ever been treated by a psychiatrist? □ yes □ no
(Please describe treatment reason, setting, and length)_____________________________________________
________________________________________________________________________________________
Have you ever been suicidal? □ yes □ no
Have you ever been homicidal? □ yes □ no
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Current:
Please list the drugs you use and when your last use was:
Drug: _______________________________________
Last used: _____________________
Drug: _______________________________________
Last used: _____________________
Drug: _______________________________________
Last used: _____________________
Drug: _______________________________________
Last used: ____________________
Are these drugs prescribed, bought on the street, or both? _______________________
Drinking Pattern: ___Daily ___Periodic ___Binge ___Weekend only
Amount typically consumed (#of drinks)? ______________________________________________
Type of Alcohol (check all that apply): ___Beer ___Wine ___Liquor
Are you currently taking Xanax, Valium, Klonopin, Ambien or any benzodiazepine? □ yes □ no
If so, which one(s) and how much? _____________________________________________________________
__________________________________________________________________________________________
Are you willing to taper off of the benzodiazepine listed above? □ yes □ no
Have you ever had a seizure from alcohol or benzo withdrawal? □ yes □ no
Are you willing to stop drinking alcohol? □ yes □ no
Are you willing to stop smoking marijuana? □ yes □ no
Have you ever had DT’s? □ yes □ no
Do you have any current or past legal issues that have resulted from your addiction? □ yes □ no
If yes, explain______________________________________________________________________________
Are you currently employed? □ yes □ no How many hours/week (avg.)? __________________________
What caused you to start using opiates originally? _________________________________________________
__________________________________________________________________________________________
Have you ever tried to quit on your own? □ yes □ no
Please describe? ____________________________________________________________________________
What are the major sources of stress in your life? __________________________________________________
__________________________________________________________________________________________
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What are your major strengths to deal with the stress in your life? _____________________________________
__________________________________________________________________________________________
What coping methods have you developed to deal with triggers to relapse? _____________________________
__________________________________________________________________________________________
What benefit do you expect from Suboxone?
_____________________________________________________
__________________________________________________________________________________________
Please describe your current living arrangements: _________________________________________________
__________________________________________________________________________________________
Does anyone in your family (mother, father, brother/sister, child, aunt/uncle or grandparent) have a current or past history of substance abuse? □ yes □ no
If yes, please list who and what substance: _______________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you have any medical conditions (diabetes, heart disease, hepatitis, HIV+, epilepsy, STDs, etc.)? □ yes □ no
If yes, please explain_________________________________________________________________________
Are you currently taking any medications to treat these conditions? □ yes □ no
(List medication and dosage)__________________________________________________________________
__________________________________________________________________________________________
Are you pregnant? ( ) N/A ( ) N ( ) Y ( ) Not Sure
List ALL of your current physicians:
__________________________________________________________________________________________
__________________________________________________________________________________________
The safety of your Suboxone medication or prescription is your responsibility. Requests for replacement
Suboxone will not be honored without an appointment.
Do you understand that following the loss or theft of your prescription, it is at the discretion of our physician to determine whether you will be allowed to continue in this program?
□ yes □ no
I have completed this form truthfully and to the best of my ability.
Signature _________________________________________ Date ______________________
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SUBOXONE NEW PATIENT INTRODUCTION
Our clinic restricts our treatment panel to a limited number of pre-qualified patients. This program accepts only patients who are serious about overcoming opiate addiction. We do not assume general medical care of
Suboxone patients. ALL patients must adhere to strict cash payment policies. This is a 13-month recovery program.
To register please complete:
STEP ONE

Read the entire packet.

Return completed forms to our office.

You will be contacted by phone before acceptance.
STEP TWO

If accepted, our office will call to schedule your first appointment.

Schedule first 3 appointments with prepayment of $350 by cash or credit card.
STEP THREE

Arrive IN WITHDRAWAL for first appointment of up to 3 hours.

Be prepared for a urine drug screen.

You will receive your prescription and you will be directed to the pharmacy to fill the prescription.

Return with filled prescription to continue the initial visit.
STEP FOUR

Return for two follow up visits, the first 2-3 days after initial visit and the second 7-10 days after initial visit (included in the prepayment made in STEP TWO)

At you 3 rd
appointment, schedule a two-week follow up with prepayment of $85 cash or credit card

Plan to schedule monthly maintenance visits thereafter. o Work/ school notes will be given as appropriate.

Plan to attend 1 session of in-office mandatory Group Therapy and 2 AA meetings monthly.

Duration of the treatment is individually determined by the patient, but will not exceed 13 months.

If a visit is missed with no warning, if you are found to be using, or fail a urine drug screen, return to
STEP ONE. You will be given a prescription for a 2-week taper dose, and you will be required to apply for re-acceptance into the program. Re-acceptance is not guaranteed. Prior missed appointment fee
($150) must be paid before reacceptance.
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SUBOXONE PATIENT RESPONSIBILITIES
I agree to store medication properly. Medication may be harmful to children, household members, guests, and pets. The pills should be stored in a safe place, out of the reach of children. If anyone besides the patients ingests the medication, the patient must call the Poison Control Center or 911 immediately.
I agree to take the medication only as prescribed. The indicated dose should be taken daily, and the patient must not adjust the dose on his/her own.
I agree to comply with the required pill counts and urine tests. Urine testing is a mandatory part of office maintenance; therefore, the patient must be prepared to give a urine sample for testing at each clinic visit. The patient should bring his or her medication to each appointment and may be asked to show the medication bottle for a pill count, including reserve medication. Patient may be asked to come in for random urine drug screens and/or pill counts and must comply within 24 hours of receiving notice.
I agree to make and prepay for another appointment in case of a lost or stolen medication.
I agree to notify the clinic in case of relapse to drug abuse. Relapse to opiate drug abuse can result in being removed from the Suboxone program. An appropriate treatment plan must be developed as soon as possible.
The physician should be informed of a relapse before random urine testing reveals it.
I agree to the guidelines of office operations. I understand the procedure for making appointments and paying for missed appointments and late cancellation fees. I have the phone number of this clinic and I understand the office hours. I understand that no medications will be prescribed by phone or on weekends. I understand that I am required to abide by these restraints in order to remain on the Suboxone treatment panel of this office.
I understand that this treatment program does not provide medical or surgical care outside the scope of routine Suboxone maintenance.
Signature _________________________________ Date ______________________
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SUBOXONE TREATMENT FINANCIAL POLICIES
Fees:
$350- Includes Initial Three Visits and 12-Step Program Materials
$85- Monthly Medication Management and Individual Counseling
$25- MANDATORY Group Meetings once monthly
Prepayment is required for all visits.
We accept credit card, debit card, money order, or cash. NO CHECKS.
The cost for the initial evaluation and Suboxone induction treatment is $350. This includes 3 visits (the initial visit along with 2 additional within 2-7 days).
Additionally, direct access to private therapy, family therapy, a life coach, yoga, and meditation are provided for a small program fee. These services are provided to aid you in your recovery.
There is a $150 cancellation fee (less than 24 hours notice) for the first visit.
The cost for follow up appointments is $85. Follow up appointments are scheduled every 2-4 weeks. Urine drug screening may be done as frequently as every visit. The cost of drug screening in our office is $55 for a full panel or $15 for a Suboxone-only panel. Payment for all prior visits must remain current in order to retain your reservation on the panel. We do not wish you to undergo sudden withdrawal from Suboxone. This will be the result if you fail to reserve and keep your appointments.
There is an $85 cancellation fee (less than 24 hours notice) for follow up appointments.
Your reservation in our limited program is secured with a paid up account. At the conclusion of your visit you will be asked to reserve your next visit.
You may be required to go to the medical lab at the end of the first office visit for blood and urine samples, metabolic profiles, HIV, and drug screening. Additional tests may be required as indicated by history and examination. Payment will be expected at the time of service. Future charges for lab tests may be billable by the lab to the patient.
Please fill in your credit card information below. This information will be used by our office for the first visit payment and future payments after your acceptance.
Credit Card Information
Type:
□ MasterCard □ Visa □ Discover
Credit Card No.: _______ _______ _______ _______
Expiration Date: ______/______ Signature: ______________________________________
Security Code: ______ (3 or 4 digit # on card) Print Name: _____________________________________
(Your signature authorizes Compass Recovery to process your credit card for any charges incurred.)
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SUBOXONE TREATMENT INFORMED CONSENT
Suboxone (buprenorphine + naloxone) is an FDA approved medication for treatment of opiate (narcotic) dependence. It can be used for detoxification or for maintenance therapy. It can cause withdrawal reactions from standard narcotics or Methadone while at the same time having a mild narcotic pain relieving effect from the Suboxone.
The use of Suboxone can result in physical dependence of the buprenorphine, but withdrawal is much milder and slower than with heroin or Methadone. If Suboxone is suddenly discontinued, patients will have only mild symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opiate withdrawal, Suboxone may be discontinued gradually, usually over several weeks or more.
Because of its narcotic-reversing effect, if you are dependent on opiates, you should be in as much withdrawal as possible when you take the first dose of Suboxone.
You must be off Methadone for at least 24 hours (after tapering yourself down to at least 40mg per day) or off of other narcotics for at least 12 hours and showing signs of withdrawal before starting Suboxone. Some patients find that it takes several days for the transition to Suboxone from the opiate they had been using. After stabilized on Suboxone, other opiates will have virtually no effect. Attempts at more opiates could result in an opiate overdose. Do not take any other medication without discussing it with your physician. Combining Suboxone with alcohol or some other medications may also be hazardous.
We do not prescribe, under any circumstances, narcotics, Methadone, or sedatives for patients desiring maintenance or detoxification from narcotics.
All Suboxone must be purchased at pharmacies. We will not supply any Suboxone.
Signature _________________________________ Date ______________________
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SUBOXONE TREATMENT FOLLOW UP APPOINTMENTS
Follow up appointments will be at least monthly.
The visits are focused on evaluating compliance and the possibility of relapse. They may include:

Film/Pill counts

Urine testing for drug abuse

An interim history of any new medical problems or social stressors

12 Step Program discussion

Prescription of medication

No refills of Suboxone will be made for any reason except during a clinic visit.

Appointments do not include evaluation or care for other problems
Dangerous behavior, relapse and relapse prevention.
The following behavior “red flags” will be addressed with the patient as soon as they are noticed:

Missing appointments

Running out of medication too soon

Taking medication off schedule

Refusing urine testing

Neglecting to mention new medication or outside treatment

Agitated behavior

Frequent or urgent inappropriate phone calls

Outbursts of anger

Lost or stolen medication

Non-payment of visits as agreed, missed appointments or cancellations within 24 hours of your appointment

Treatment may be discontinued if these behaviors occur
SUBOXONE TREATMENT MAINTENANCE
Suboxone treatment may be discontinued for several reasons:

If you are unable to stop your dependence, or if you continue to feel like using narcotics, even at the top doses of Suboxone, the doctor will discontinue treatment with Suboxone and you will be required to seek help elsewhere.

If you do not abide by our agreements you may be discharged from the Suboxone treatment program.

Prompt payment of clinic fees is part of this program. If your account does not remain current, appointments cannot be scheduled. If appointments cannot be kept as agreed, your status as an active patient will be cancelled.

In the case of an allergic reaction to medication, Suboxone must be discontinued.

Dangerous or inappropriate behavior will result in your discharge from the Suboxone treatment. o In the case of dangerous behavior there will be no two-week taper. You will be discharged and asked not to return.

Not attending mandatory group and/or mandatory 2 AA meetings.
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THERAPY REQUIREMENTS

Group therapy will be held in the lobby of Prince Ave Primary Care from 6:30-7:30 every Tuesday and
Wednesday.

You will be required to attend at least 1 group therapy session each month. You will sign up at your monthly appointment.

Group therapy will include 12 Step Principles, and learning other life skills and coping mechanisms to aid in your recovery. Through the process of sharing your recovery and abstinence, you will strengthen your pursuit of recovery.

Group success depends on consistent attendance and dedication from every individual. This should be a place of compassion of surrender.
 You will be required to attend at least 2 AA meetings monthly and obtain the signature of the meetings’ leader.
CERTIFICATES

The sixth month and the twelfth month of sobriety Dr. Gibson will award you with a certificate of congratulations.

This reward process is important so that you are able to recognize your significant growth.
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SUBOXONE MATERIALS CONFIRMATION
INITIAL BELOW:
Questionnaire ________
New Patient Introduction _________
Patient Responsibilities _________
Financial Policy _________
Follow Up Protocols _________
Maintenance __________
Informed Consent _________
Therapy________
Certificates________
My signature below and initials by the name of each individually listed document, certifies that I fully understand and agree to the contents of each document.
Signature ____________________________________________
Printed name _________________________________________ Date_____________________
FOR OFFICE USE ONLY
INITIAL VISIT DATE: ____________________________
SECOND VISIT DATE: ___________________________
THIRD VISIT DATE: _____________________________
ADDITIONAL VISIT DATES: _______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
URINE DRUG SCREEN DATES: _____________________________________________________________
__________________________________________________________________________________________
GROUP THERAPY MEETING DATES: ________________________________________________________
__________________________________________________________________________________________
AA MEETING DATES: _____________________________________________________________________
__________________________________________________________________________________________
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