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patient forms

Complete all of our enrollment forms and questionnaires online. Questions? Call 877-437-2101. 

1. Enrollment

2. Medical History

3. Text Consent

4. HIPAA Authorization

5. Program Responsibilities

6. Treatment Contract

7. Accountability Partner      Consent

8. Relapse Prevention Plan

Program Responsibilities

You must understand that medication alone is not sufficient treatment and agree to participate in the recommended treatment of counseling which is an important part of this program. You will be required to attend group sessions four times a month in order to meet the requirement of attending four hours of group in a 28-day period. Failure to do so will result in the inability to see the prescribing physician for prescriptions.

 

Addiction Care 101 does not accept insurance for this treatment program and all fees are cash and debit cards/credits only. A101 does not accept checks for the addiction program. All fees are required to be paid in full on the date of service; failure to do can impact your ability to receive your prescription.

9. Drug Abuse Screening

10. Probation Agreement

Only for patients on probation.

A101 Virtual Group Times

Monday: 7 – 8 p.m.

Tuesday: 8:30 – 9:30 a.m. | 5 – 6 p.m.

Wednesday: 10 – 11 a.m. | 3 – 4 p.m. | 7 – 8 p.m.

Thursday: 8:30 – 9:30 a.m. | 7 – 8 p.m.

Friday: 12 – 1 p.m.

 

Dial-in: 1-512-489-3100 Ext. 4820351

Phone: 877-437-2101

Fax: 910-399-2190

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