Medication-Assisted Treatment (MAT) Intake
Please complete this intake to support your MAT induction or maintenance care. All information is confidential and used only for your treatment team.
Full Name
*
First Name
Last Name
Best Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current MAT Treatment Stage
*
Induction
Maintenance
Re-induction
Primary Substance Use History
*
Please Select
Opioids (heroin, prescription opioids)
Alcohol
Stimulants (cocaine, methamphetamine)
Benzodiazepines
Other (please specify)
Are you currently experiencing withdrawal symptoms?
*
Yes
No
Have you previously participated in MAT?
*
Yes
No
Current Medications and Known Allergies
*
Are you currently pregnant or possibly pregnant?
*
Yes
No
Not applicable
Clinician or Clinic Name
*
Emergency Contact Name and Preferred Follow-Up Method
*
Submit Intake
Should be Empty: