Footprints

Footprints: Drug and Alcohol Treatment Program

Center for Emotional Health offers services from Footprints at all of our office locations in North Carolina, including Charlotte. Footprints is a drug and alcohol treatment center that helps patients overcome substance abuse.

For patients age 16 and up, we provide outpatient individual therapy, group therapy, addiction therapy for those who have already detoxed, and medication management for Suboxone, Sublocade, and Vivitrol. Please call us to schedule an appointment or learn more about our treatment center.

Footprints New Patient Paperwork

Please complete the following forms and submit them to our office. You may complete the paperwork digitally, or print and submit the forms. Printable forms are located at the bottom of the page.

Suboxone / Sublocade New Patients – Additional Forms

Buprenorphine Agreement

Because Buprenorphine is a potent controlled medication used to treat addiction, we require that you notify us prior to taking any medications in addition to your dispensed medication at CEH. This includes prescription and over-the-counter medication. We want to ensure that the medications you take with buprenorphine do not cause unwanted or risky interactions. Our intent is to keep you safe with this policy.

Buprenorphine - While we know that sometimes it may be necessary for you to take short-acting pills while on buprenorphine/buprenorphine-naloxone, (for example if you have surgery or a dental procedure) we ask that you let us know before any hospital admission or any medical procedure. It is imperative that you notify the doctor performing the procedure that you are taking buprenorphine. The CEH provider, along with the doctor performing the procedure will need to determine the best course of action for your pain management through the course of the procedure and its aftermath. After the procedure, the client will be required to bring records of procedure/hospitalization for the provider's review.

Records needed:

Discharge paperwork which should contain admission and discharge dates
Medications given under medical care
Medications prescribed
Final prognosis

Clients may be required to see the provider to re-induce onto buprenorphine/buprenorphine-naloxone depending on how long the client missed dosing and other factors.

We do check with the North Carolina and South Carolina systems that track all prescribed controlled substances, and if we later find out you have been getting prescriptions for addictive medications that you did not tell us about, we may lower you back to level 1 where you have to come to the office once a week until you are stable again. In extreme situations (for example, if a patient is getting buprenorphine/buprenorphine-naloxone from another source) it may, unfortunately, be necessary to discharge a patient from our facility.

Thank you for keeping us informed of all your health concerns and medications; we can give you better care if we know all of the other medications you are taking.

Thank you,
CEH Footprints Team

Patient Name:(Required)

First Last

Date of Birth:(Required)

Date:(Required)

Email(Required)

Name

This field is for validation purposes and should be left unchanged.

Pregnancy Consent Form

Pregnancy Consent

The FDA has not approved suboxone/buprenorphine as completely safe for use during pregnancy. The decision on whether or not to continue the medication during pregnancy must be made after a full and open discussion of the risks and benefits of that decision.

It is important that you inform your doctor if you are now or intend to become pregnant.

Suboxone/buprenorphine can be a way to maintain pregnancy as healthfully as possible while also stopping the use of the opiate of choice without triggering withdrawal symptoms that may cause a spontaneous abortion. Throughout the pregnancy, your infant could become dependent on the drug. This can cause life-threatening withdrawal symptoms in the infant after the infant is born. Adequate advance planning will allow for the greatest physical and mental well-being of mother and infant.

I understand and agree.

Patient Name(Required)

First Last

Email(Required)

Date(Required)

Phone

This field is for validation purposes and should be left unchanged.

Vivitrol New Patients – Additional Forms

Vivitrol Agreement

Vivitrol Treatment Acknowledgment and Consent(Required)

I understand that Dr. Stoudmire is prescribing Vivitrol/Naltrexone to manage my alcohol dependence or opioid dependence. The risks, side effects, and benefits of treatment have been explained to me, and I agree to the following instructions. Failure to follow these instructions may result in not having the medication prescribed.

1. I will participate in any other treatments recommended by my provider, including group therapy.

2. I will take my medications exactly as prescribed and will not change the medication or dosage without advance approval from any provider. I will provide my medication for pill counts at the provider's request. I will not request early refills.

3. I will keep regular appointments with my provider.

4. I will inform my provider within one business day if I am hospitalized for any reason, or if I have another condition that requires the prescription of a controlled drug (like narcotics, tranquilizers, barbiturates, or stimulants).

5. I will choose one pharmacy where all my prescriptions will be filled.

6. I understand that lost or stolen prescriptions will not be replaced, so I will keep my prescription and medication in a safe place or lock box.

7. I agree to avoid all illegal and recreational drugs (including alcohol) and will provide urine or blood specimens at the doctor's request to monitor my compliance.

8. I agree to follow my doctor's recommendations regarding the operation of motor vehicles or heavy machinery while taking this medication.

9. Refills will be made only during regular office hours, which are Monday-Friday from 8 am to 5 pm. Refills will not be made at night, on weekends or during holidays. I am responsible for keeping track of my remaining medication, so that I can call for refills in advance. This way, I will not run out of medication.

I affirm and agree to the provisions of this agreement

Pharmacy Name(Required)

Please provide the name of the pharmacy where all your prescriptions will be filled.

Pharmacy Phone(Required)

Pharmacy Fax(Required)

Pharmacy Address(Required)

Street Address Address Line 2 City State ZIP Code

Patient Name(Required)

By entering my name here, I affirm and agree to the conditions of treatment as outlined above.

First Last

Date(Required)

This field is for validation purposes and should be left unchanged.

Pregnancy Consent Form

Pregnancy Consent

I understand and agree.

Patient Name(Required)

First Last

Email(Required)

Date(Required)

Name

This field is for validation purposes and should be left unchanged.

HIPAA Authorization Consent Form

This form authorizes the release of your medical information for patient support services.

Step 1 of 2

HIPAA Consent(Required)

PATIENT AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

By signing and printing my name below, I authorize 1. my prescribing healthcare provider, 2. the healthcare provider who will administer VIVITROL to me, 3. the pharmacy(ies) to which my VIVITROL prescription is sent for fulfillment (the “Pharmacy”), and 4. my health plans and insurers (collectively, my “Healthcare Entities”) to use and disclose to: 1. Alkermes, Inc. and the companies working with Alkermes, Inc. to provide the VIVITROL patient support services I request, which are United BioSource Corporation, IQVIA, Inc., (collectively, “Alkermes”) and 2. my Contact(s) listed above (together with Alkermes, the “Recipients”) health information related to my medical condition, including information about my drug or alcohol addiction, my mental health condition(s), my treatment with VIVITROL, my insurance coverage, as well as the information requested in this form (taken together, “Information”) for the specific purposes of allowing Alkermes to facilitate: 1. ordering, delivering and administering VIVITROL, 2. conducting reimbursement verification and obtaining payment from my health plan(s) and insurer(s), 3. providing me with educational and therapy support services by mail, text-messaging, e-mail, and/or telephone, which may include sending me product information materials, treatment reminders, and motivational messages, 4. referring me to, or determining my eligibility for, other programs, foundations or alternative sources of funding or coverage to help me with the costs of VIVITROL and 5. reviewing and analyzing fulfillment of VIVITROL prescriptions. Information May Be Further Disclosed: I understand that Information disclosed pursuant to this authorization could be re-disclosed by a Recipient and may no longer be protected by federal privacy law (HIPAA).

I understand that signing this authorization is voluntary and if I do not sign this authorization it will not affect my ability to obtain treatment, insurance, or insurance benefits from my Healthcare Entities. I understand, however, that if I do not sign this authorization, I will not be eligible to receive the educational, patient support, or other services described above, which are being provided by, or on behalf of, Alkermes. I will consult with my healthcare provider before making any treatment decisions. I understand I have the right to receive a copy of this authorization after I sign. I understand that the Pharmacy may receive payment from Alkermes, Inc. in exchange for Information.

I may withdraw this authorization at any time by mailing or faxing a written request to Vivitrol2gether, 852 Winter Street, Waltham, MA 02451, 1-877-329-8484.

I agree.(Required)

Contacts Consent(Required)

By signing below, I authorize my Contact(s), listed below, to receive logistical and administrative information related to my treatment, such as appointment reminders, and to make decisions on my behalf—for which I will remain liable—regarding the delivery of VIVITROL® (naltrexone for extended-release injectable suspension). Alkermes is not liable for any decision(s) made by the Contact(s) or actions taken in reliance on such Contact(s) decisions.

I agree.(Required)

Patient Name(Required)

First Last

Date:(Required)

Email(Required)

Please list any contacts as set forth above.

Designee 1 Name:

First Last

Designee 1 Phone:

Relationship to Patient

Designee 2 Name:

First Last

Designee 2 Phone:

Relationship to Patient:

Printable Forms

If you prefer to print your forms and complete them manually, please use the forms below. Once you have completed those forms, you may scan and send them to our office at newpatients@cehcharlotte.com. If you prefer, you may fax them to (704) 547-3150.

Printable Patient Forms

Suboxone / Sublocade New Patient Paperwork

Vivitrol New Patient Paperwork

Footprints

Footprints: Drug and Alcohol Treatment Program

Footprints New Patient Paperwork

CEH New Patient Paperwork

Patient Health Questionnaires

Center for Emotional Health Privacy Practices

Center for Emotional Health Release of Information

Suboxone / Sublocade New Patients – Additional Forms

Buprenorphine Agreement

Pregnancy Consent

Vivitrol New Patients – Additional Forms

Pregnancy Consent

HIPAA Authorization Consent Form

Printable Forms

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