Please complete the following. When complete his done and it will send over your responses. 

Question Title

* 1. Full Name

Question Title

* 2. Email Address

Question Title

* 3. Full SSN

Question Title

* 4. Date of Birth

Question Title

* 5. If you have been hospitalized for mental health, what were the reasons?

Question Title

* 6. How old were you when you first used and tell us about the progression? (Example: Age/Substance)

Question Title

* 7. Is opiates/fentanyl your primary drug of use?

Question Title

* 8. When did you last use? 

Question Title

* 9. Route of delivery for opiates/fentanyl?

Question Title

* 10. Are there other substances that you are using?

Question Title

* 11. If yes, what other substances are you using?

Question Title

* 12. Do you have any health conditions that you want to share with us?

Question Title

* 13. Do you have a history of assaultive or violent behavior towards other people?

Question Title

* 14. If yes, explain

Question Title

* 15. Do you have current thoughts of violence towards other people? 

Question Title

* 16. If yes, explain

Question Title

* 17. Do you have a history of self-harm?

Question Title

* 18. If yes, explain

Question Title

* 19. In the past few weeks, have you wish that you were dead? 

Question Title

* 20. If yes, please explain

Question Title

* 21. In the past few weeks, have you believe that your friends or family would be better off if you were dead?

Question Title

* 22. If yes, please explain

Question Title

* 23. In the past few weeks, have you thought about killings yourself?

Question Title

* 24. Do you currently have a plan to kill yourself?

0 of 103 answered
 

T