Pre-Assessment Screening - ELM Freedom Tree

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Cost of Pre-Assessment is $49.95

Pre-Assessment Questions

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Name(Required)

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Email(Required)

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1. Do you have difficulty with prescribed or unprescribed pain meds?(Required)

Yes

No

2. Are you currently taking Methadone, Suboxone, Buprenorphine, Vivitrol or Sublocade?(Required)

Yes

No

3. Do you currently have difficulty with alcohol?(Required)

Yes

No

4. Are you currently taking Methadone, Suboxone, Buprenorphine, Vivitrol or Sublocade?(Required)

Yes

No

5. Are you willing to try a 7-day starter trial?(Required)

Yes

No

6. How long have you been struggling with a substance use disorder??(Required)

1-2

3-5

6-10

> 10

7. Are willing to follow the wellness plan for your recovery created by your medical team?(Required)

Yes

No

8. Do you agree that as this science makes them significantly feel better, quickly & empowers them, they will not stop treatment, continue VRN efforts to search for & treat underlying root causes.(Required)

Yes

No

9. Do you further acknowledge that although VRN's latest scientific breakthroughs are "game changing", there are no magic, quick fix devices/shots, and they must be the key player?(Required)

Yes

No

10. Are willing to: honestly, fully, complete a longer survey, be interviewed, and then follow the professionally, individually prescribed, local, health centered, extended care contract?(Required)

Yes

No

11. Because in matters of medicine "one size-usually fits no one, and if your case requires you to be IMMEDIATELY referred to a medical specialist or emergency care, will you comply?(Required)

Yes

No

12. Do you agree that when science separates you from significant pain, & prevents relapse, you must emotionally, socially, vocationally, & economically ultimately control your extended care plan?(Required)

Yes

No

13. Do you agree to comply with the VRN extended care plan even if it means: changing relationships, life style, social habits, career, unemployment status, and training and more education.(Required)

Yes

No

14. Do you agree that if you are successful with the program, you will consider VRN opportunities (volunteer) to assist others that need similar treatment?(Required)

Yes

No

15. Do you have a “significant other” family, friend, mentor, group, church, or other who would appear with you at assessment and/or appointments, and assist with your treatment?(Required)

Yes

No

16. Do you have a current associated legal, criminal, employer, professional license, divorce, custody, school/college discipline, “significant other” substance use disorder caused problem?(Required)

Yes

No

17. Do you agree to: a portion or all of your VRN counseling being on a conference call and/or FaceTime/Skype; 5 days wearing a small device the size of a hearing aid, and an Injection?(Required)

Yes

No

Consent(Required)

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Prevent Drug and Alcohol Relaple

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