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.

New Patient Intake Form

New Patient Health Questionnaire

Patient Health Questionnaires

These questionnaires must only be completed by patients ages 16 and older.

Step 1 of 3 - Patient Information

Patient Name(Required)

Notice of Privacy Practices

Center for Emotional Health Privacy Practices

Notice of Privacy Practices
This notice describes how medical and drug and alcohol related information about you may be used and disclosed and how you can get access to this information. Please review it carefully.(Required)
Name of Patient(Required)
Name of Parent / Legal Guardian
This field is for validation purposes and should be left unchanged.

Release of Information

Center for Emotional Health Release of Information

Step 1 of 3 - Patient Information

This notice describes how medical and drug and alcohol related information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Phone number: 704-237-4240
Fax number: 704-547-3150
Email: info@cehcharlotte.com
Patient Information:(Required)
I give permission to release the health information of:
Patient Home Address(Required)

Suboxone / Sublocade New Patients – Additional Forms
Buprenorphine Agreement

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)
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.(Required)
Patient Name(Required)
This field is for validation purposes and should be left unchanged.

Vivitrol New Patients – Additional Forms
Vivitrol Agreement

Vivitrol Treatment Acknowledgment and Consent(Required)
Please provide the name of the pharmacy where all your prescriptions will be filled.
Pharmacy Address(Required)
Patient Name(Required)
By entering my name here, I affirm and agree to the conditions of treatment as outlined above.
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.(Required)
Patient Name(Required)
This field is for validation purposes and should be left unchanged.

HIPAA Authorization Consent Form

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.