CATAR-PRESCREENING
(*) denotes a required answers)
01- What is your name? (Asked for reference use only) *
02- What is your drug of choice?
This would be your FAVORITE drug?
This is your PREFERRED drug of choice.
This is the drug you would choose if it were available.
This does not have to be the drug you are currently using. *
METHADONE (DOLOPHINE)
HYDROCODONE (VICODIN, HYCODAN)
MORPHINE (or MS CONTIN)
PENTAZOCINE (TALWIN)
PROPOXYPHENE (DARVON-DARVACET)
OXYMORPHONE (NUMORPHAN)
MEPERIDINE (DEMEROL)
HYDROMORPHONE (DILAUDID)
HEROIN
CODEINE
OXYCODONE (PERCODAN, OXYCONTIN)
FENTANYL (DURAGESIC- ATIQ)
OTHER
03- If other was selected what is your drug?
(Be specific, and do not list the class of drug.)
04- How long have you been taking drugs on a daily basis? *
05- What drug are you taking now? - and -
How much are you taking? Daily
06- How much are you taking? Weekly
07- How much are you taking? Monthly
08- When was the last time you used? *
09- How much did you use? *
10- Are you taking drugs other than your drug/drugs of choice? *
YES
NO
11- If "YES" what did you take?
12- If “yes”, when was last use?
13- If “yes”, how much did you use?
14- Do you have a reliable means of transportation? *
YES
NO
15- Can you attend six days a week for the first 90 days?
Monday thru Saturday *
YES
NO
16- Can you afford to pay for your treatment out of pocket?
(Weekly payments are required)
If no, please answer the next question: *
YES
NO
17- If you are unable to pay out of pocket,
we may be able to ofer you a referral:
Do you have any medical insurance?
We do NOT take insurance,
but we may be able to offer you a referral if requested.
*
YES
NO
18- What STATE / COUNTY do you live in?
19- What is your email address?
20- What is your phone number?
21- How would you like us to contact you?
22- Where did you hear about CATAR CLINIC?
20- What other helpful information can you provide?
This is anything you believe would be benificial for us to know.
Previous treatment, current treatment, etc
If this form is being completed by a 3rd party, please let us know.
For referrals, please provide information about your program.