Patient forms
Living Free 365 Patient Forms
Paperwork for our Suboxone outpatient program. It is straightforward, and nobody at the front desk will treat you differently for carrying it.
The forms in this packet
You can print these and complete them before your visit, or arrive 15 minutes early and fill them in here.
Living Free 365 Form
Intake and treatment agreement for the Living Free 365 program.
Living Free 365 FormPDF · 246 KBPatient Consent for Treatment
Your written consent to begin care with our clinicians.
Patient Consent for TreatmentPDF · 384 KBPTSD Check List
A brief screening checklist for post-traumatic stress symptoms.
PTSD Check ListPDF · 96 KBNew Patient Form
Contact details, insurance information and basic history.
New Patient FormPDF · 380 KBPatient Health Questionnaire
A short symptom and history questionnaire your clinician reviews before the visit.
Patient Health QuestionnairePDF · 356 KBMedical Records Release
Authorises us to request or send records to another provider.
Medical Records ReleasePDF · 58 KBDesignated Caregiver Form
Names a caregiver who may act on your behalf in the program.
Designated Caregiver FormPDF · 50 KBAdult Patient Signature Page — Living Free 365 / Medical Cannabis
Signature page for adult patients in the medical cannabis program.
Adult Patient Signature Page — Living Free 365 / Medical CannabisPDF · 46 KBMinor Patient Signature Page — Living Free 365 / Medical Cannabis
Signature page completed by a parent or guardian for a patient under 18.
Minor Patient Signature Page — Living Free 365 / Medical CannabisPDF · 70 KBVisiting Patient Signature Page — Living Free 365 / Medical Cannabis
Signature page for visiting patients certified in another state.
Visiting Patient Signature Page — Living Free 365 / Medical CannabisPDF · 45 KB
Looking for a different packet? Patient Forms or TMS Patient Forms.
What is in the packet
- Patient information and medical history
- Medication history, including current opioid use and any other prescriptions
- Treatment agreement for medication-assisted treatment
- Consent for Suboxone treatment and monitoring
- Confidentiality notice covering substance use disorder records, which carry protections beyond standard HIPAA
Confidentiality
Substance use disorder treatment records are protected under federal rules that are stricter than ordinary medical privacy. They are not released to employers, family or other providers without your written authorisation.
Be accurate, not tidy
The medication section is a safety document. Underreporting what you are taking makes your first dose less safe, not less embarrassing. Your physician has seen every version of this and is here to treat it.
Program fax
Referring providers and pharmacies can fax records to (502) 736-0140. Patients should call (502) 454-8800 rather than faxing personal documents.
What happens next
- 1Call (502) 454-8800 and say you are asking about LivingFree365.
- 2We send the packet and schedule your evaluation with a program physician.
- 3Bring the completed forms, photo ID and your insurance card to that appointment.
Prefer to talk? Call (502) 454-8800. We respond within one business day.
Request an appointment
Tell us how to reach you and what you're looking for. We'll confirm your insurance, answer your questions, and find a time that works. No long intake before you hear from a person.
- We respond within one business day.
- Most insurance accepted, including TRICARE and Medicare.
- In-office visits on Newburg Road, plus telehealth.
