A New Beginning... A New Outlook... A New You... Click on any category to view the available Patient Forms, Records, Registration & Documents Contact US for Patient Forms OR Click on the link we have provided for each form All forms are in Microsoft Word (.doc) format Confidentiality of Patient Records Consent Forms & Treatment Screening Tests & DSM-IV Criteria Patient Records, Reports & Questionnaires Consent Forms & Treatment Patient Treatment Contract     View the "Patient Treatment Contract" Form Appointed Pharmacy Consent     View the "Appointed Pharmacy Consent" Form Consent to Release/Receive Confidential Information     View the "Consent to Release/Receive Confidential Information" Form Consent to Store, Dispense & Destroy Medication     View the "Consent to Store, Dispense & Destroy Medication" Form Methadone Transfer Consent     View the "Methadone Transfer Consent" Form Telephone Appointment Reminder Consent     View the "Telephone Appointment Reminder Consent" Form Return to Index Patient Records, Reports & Questionnaires Home Dosing Record     View the "Home Dosing Record" Form Patient Intake: Medical History (To be completed by patient)     View the "Patient Intake: Medical History (To be completed by patient)" Form Patient Intake: Social/Family History (To be completed by patient)     View the "Patient Intake: Social/Family History (To be completed by patient)" Form Therapy Progress Report     View the "Therapy Progress Report" Form CAGE Questionnaire     View the "CAGE Questionnaire" Form Return to Index Screening Tests & DSM-IV Criteria Brief Michigan Alcohol Screening Test (MAST)     View the "Brief Michigan Alcohol Screening Test (MAST)" Form Drug Abuse Screening Test (DAST)     View the "Drug Abuse Screening Test (DAST)" Form PreTreatment Screening     View the "PreTreatment Screening" Form DSM-IV Criteria for Substance Dependence and Abuse     View the "DSM-IV Criteria for Substance Dependence and Abuse" Form DSM-IV Criteria for Opioid Dependence Diagnosis: Worksheet     View the "DSM-IV Criteria for Opioid Dependence Diagnosis: Worksheet" Form Return to Index 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. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities. Return to Index Home Page | About Us | Signs of Dependence | F.A.Q. (Frequently Asked Questions)  | Treatment Information  | Your First Appointment | Patient Forms | Internet Links  | Privacy Policy  | Contact Subox-Detox Center  | e-mail Subox-Detox Center  | Make "Subox-Detox Center" your Home Page Copyright ©2006, 2007 Subox-Detox Center (All Rights Reserved) The Contents and Graphics of the "Subox-Detox Center" MAY NOT be copied or reproduced in any form without our consent. You may also view our Privacy Policy.