1. Do you live in New Mexico and are you at least 18 years old? *

Yes

No

I’m sorry, we can only treat patients who are at least 18 years old and live in New Mexico. *

Check the box to end the survey.

2. Do you have Medicare/Medicaid? *

Yes

No

I am sorry, we are currently not taking patients with Medicare/Medicaid. *

Please check the box to end the survey.

3. Are you pregnant? *

Yes

No

Thank you for considering us for your care, but we believe it is in your best interest to consult a psychiatrist or psychiatric nurse practitioner for your care. *

Please check the box to end the survey.

4. Are you currently addicted to opioids or have a history of opioid addiction? *

Yes

No

I am sorry, you are not a candidate for our program. *

Please check the box to end the survey.

5. Do you have an allergy to Suboxone, buprenorphine, or naloxone? *

Yes

No

I am very sorry, you are not a candidate for treatment with Suboxone. *

Please check the box to end the survey.

6. Are you currently taking Methadone, benzodiazepines (such as Xanax, Ativan, Valium, Klonopin, etc.), sedative medications (such as Ambien or Lunesta), muscle relaxers, or Miltown? *

Yes

No

Thank you very much for considering us for your care, but we believe it is in your best interest to consult a psychiatrist or psychiatric nurse practitioner for your care. *

Please check the box to end the survey.

7. Do you have alcohol dependence? *

Yes

No

We appreciate you for considering us for your care, but we believe it is in your best interest to consult a psychiatrist or psychiatric nurse practitioner for your care. *

Please check the box to end the survey.

8. Do you have a history of chest pain that has not been evaluated? *

Yes

No

I am sorry, you are not a candidate for treatment with Suboxone until you have been assessed for cardiac risk prior to proceeding with the stress of starting Suboxone. *

Please check the box to end the survey.

9. Do you have unstable heart problems, severe liver disease, severe lung disease, unstable psychiatric illness, are you suicidal, or are you homicidal? *

Yes

No

Thank you for considering us for your care. However, we believe it is in your best interest to consult a psychiatrist or psychiatric nurse practitioner for your care. *

Please check the box to end the survey.

10. Are you interested in outpatient telemedicine therapy with Suboxone/Buprenorphine at Rescue Recovery? *

Yes

No

Thank you for your time and interest in our program. We wish you the very best on your recovery journey. *

Please check the box to end the survey.

Please go back to the previous screen and choose an option. Or check the box below to quit. *

I want to exit the survey.

Congratulations! You are a candidate! Please fill out the contact form on the next page and someone will be in contact soon. Click the right Arrow to go to the next screen.

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