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Pennsylvania Referral Form

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    Positive Recovery Solutions
    Supplemental Form

    Participant Name:

    Participant Date of Birth

    Coordinator Name:

    Coordinator Phone/Extension

    Location to be scheduled

    Date of last use of substance/alcohol

    Allergies

    Participant received Revia/Naltrexone in the past?

    Participant received Vivitrol in the past?

    *If Yes, Date of last Vivitrol Injection:

    Sublocade (Buprenorphine) is a once monthly injection given in your stomach under your skin (subcutaneous) that provides a slow release of medication over 28 days.

    Has Participant received Sublocade in the past?

    *If Yes, Date of last Sublocade Injection:

    Pharmacy Information:

    Notes:

    I agree to release my information to the secondary contact, confirm future appointments, and to release my information to the counselor listed below

    *Name:

    *Date:

    Medication Assisted Treatment Patient Demographic Sheet Vivitrol Referrals for Positive Recovery Solutions

    *County of Referral:

    *Patient Name:

    *DOB:

    *Sex:

    *SS#:

    *Valid Phone Number:

    *Address:

    City:

    State:

    Zip Code:

    *Drug of choice:
    *Outpatient Drug & Alcohol Location:

    Name of Vivitrol Coordinator / Lead Therapist / Lead Counselor at Location:

    Phone Number / Email For Vivitrol Lead at Location:

    *Patients Counselor Name:

    *Phone Number:

    *Person making the referral:

    *Email/Phone #

    *Insurance:

    *Primary Insurance Company:

    *ID/Group#

    Secondary Insurance Company:

    ID/Group#

    *Patients Secondary Contact Name

    *Relationship to Patient:

    *Phone Number:

    Note(s):

    Positive Recovery Solutions Vivitrol Treatment Consent

    I, agree to treatment with Vivitrol. I understand that Vivitrol is an intramuscular injectable medication and needs to be given in the gluteal muscle. Positive Recovery Solutions LLC has explained the potential risks and side effects, including but not limited to pain at the injection site, unintended precipitation of opioid withdrawal, insomnia, nausea, vomiting, abdominal pain, dry mouth, local site reaction such as redness/rash and muscle cramps with more serious but rare occurrences including abscess formation at the injection site which may need further attention, serious allergic reaction, eosinophilic pneumonia, depression, and suicidality.

    Vivitrol and Alcohol Dependence

    I, understand that although I am receiving Vivitrol for Alcohol/Opioid dependence I am still subject to consequences of alcohol impairment if I choose to consume alcohol with on Vivitrol.

    Consequences including but not limited to alcohol poisoning, slurred speech, drowsiness, distorted vision/hearing, cognitive function impairment, DUI, impaired gait and others are still applicable while receiving

    Vivitrol/Naltrexone. I have discussed any questions I may have and fully understand the use of Vivitrol for my alcohol/opioid dependence.

    PRS Practices and Policies Regarding Discharge from Treatment

    PRS strives to provide compassionate care for our patients. In the interest of ensuring that our patients receive appropriate care from PRS, there are guidelines that the patient must adhere to or be immediately discharged from treatment. Any threat or act of violence (including verbal) towards staff or other patients will be cause for immediately discharged. Any submission of urine specimen that is not your own or altered in any way is cause or immediate discharge. In the event the urine specimen is not the appropriate temperature at time of submission, the patient agrees to resubmit a specimen with the supervision of PRS Staff. If the patient refuses, PRS will consider the first specimen altered and the patient will be discharged immediately. PRS CONSIDERS A PATIENT

    WHO HAD THREE POSITIVE URINE DRUG SCREENS DURING THEIR TREATMENT TO BE AN INAPPROPRIATE CANDIDATE FOR CONTINUED TREATMENT ON VIVITROL/NALTREXONE. PATIENT WILL BE CONSIDERED HIGH RISK FOR OVERDOSE/DEATH AND WILL BE REFERRED OUT TO ALTERNATIVE TREATMENT. Discontinuing recommended Behavioral Health treatment as required by patient’s insurance coverage will be cause for discharge.

    By signing this agreement, patient agrees that they understand the practices and policies regarding discharge from treatment as well as side effects and potential risks from the treatment of Vivitrol/Naltrexone. All questions have been asked and answered by the staff of Positive Recovery Solutions LLC.

    Patient Signature:

    Date: