Opiate Dependence

Interested in participating in an opiate dependence study?

Fill out the form below to see if you qualify.

First Name*

Last Name*


Phone Number*

What medication are you currently taking for pain?

How often are you taking this medication?
Once a dayTwice a dayThree times a dayMore than three times a Day

How long have you been taking this medication?
Less than 1 month1-6 Months6-12 MonthsMore than a year

Have you been diagnosed with any other psychiatric conditions?

SchizophreniaBipolar DisorderAnxietyDepressionSubstance AbusePost-Traumatic Stress DisorderOther - Please Specify

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