IT'S FINALLY POSSIBLE TO PREVENT DRUG & ALCOHOL RELAPSE!

GET TESTED RIGHT NOW BY TAKING A QUICK SURVEY:

Someone claiming they want to
Completely Quit: Pain Meds, Meth, Suboxone?
Truth or Dare!
Dare them to take 15
Minutes and Prove it!

SEE IF YOU OR A LOVED ONE QUALIFIES TODAY

A majority of “Yes Answers” to the following Questions will certainly save the quality and maybe life, itself.

How it Works

Fill Out The Survey

We'll review your qualifications

We'll follow up to discuss your results and get started!

High On Life

SAD Substance

Total Abstinence

Medicine Assisted

SACS 2 Prong

Cost = $150.00 (Payment required at end of survey)

"*" indicates required fields

Step 1 of 44

URL

This field is for validation purposes and should be left unchanged.

1. Initial Information About You

Unique Document ID

I have completely read the instructions and understand the purpose of the screening tool.*

Yes

I agree to ALL program requirements that may develop as a result of this questionnaire. (This is a condition for program participation.)*

Yes

I have voluntarily requested to be evaluated for the program.*

Yes

I knowingly, intelligently and voluntarily waive all rights of any privilege that may result from this questionnaire or participation in the SACS program. I understand to participate in this program a full waiver of confidentiality within my treatment team is paramount to my success. (This includes but is not exclusive to rights of confidentiality between providers in the SACS network).*

Yes

I agree to participate in ongoing research in the development and implementation of this screening tool. This will not include any personally identifying information about me.*

Yes

Name*

Prefix First Middle Last

Birth Date*

MM slash DD slash YYYY

Marital Status*

Enter Email Confirm Email

Phone*

Alternate Phone

May we Call You at Home?*

Yes

May we leave a voice message?*

Yes

May we send you a message via email?*

Yes

May we send you a message via text?*

Yes

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

2. ELM Financial Responsibility, Philosophy, and Policies

ELM Financial Responsibility Philosophy & Policies Assessment Questions Private Pay Compensation Only: For several compelling reasons all areas of ELM Service and Material Provisions departments must strictly adhere to the Universal ELM Private Pay Only Policy for any and all ELM or ELM Professional Referral Member services. Over the years the founders of ELM almost immediately recognized that it could not attract the level of professionals necessary to begin and sustain its mission statements unless and only until, there was a way to “compensate” those professionals and support personnel, as well as the sustain ongoing ELM expenses associated with technology and publication outreach. However, at the same time we want to immediately and forcefully emphasize: ELM nonprofit, neutrality; and the ELM constant emphasis on the word “compensation”. Definition: (monies owed as a recompense to an injured or otherwise disadvantaged party by the party responsible.) (1) ELM must be at least “compensated” or it cannot survive and remain a reliable location of the latest, and best neutral, dependable information in Education, Law and Medicine. (2) ELM professionals fundamentally believe that the end users (patient, client, student, presenter, provider, general public) should and must always, unless otherwise verifiably impossible, assume a reasonable amount of burden and responsibility or ELM total team collaboration would be fatally impacted from the onset.(3) In recognition the above ELM does offer payment options, card acceptance, and a limited number of scholarships and grants, upon successful application and/or assessment. (4) Although, with no guarantee, ELM professionals agree to assist you by providing you information on what if any possibility exists for you to be reimbursed by insurance/other or other, all ELM costs and fees must be fully paid-up front. ELM Inc. neutral, not-for-profit was founded and has been maintained by a consortium of completely independent, collaborating, like-minded, multidiscipline, multilocation professionals, favoring no particular: person, entity, profession, methodology, professional tool, device, or medication, if any. Fees for any recommended ELM Salient Assessment Services will vary depending on the results of your evaluation, including any follow up assessment and other services that are pertinent to your case. I Understand. There may be some instances if you have an active health insurance policy/other that it may cover some of the costs but there is no guarantee. With no guarantee, ELM professionals agree to assist you by providing you information on what if any possibility exists for you to be reimbursed by insurance/or other, all ELM costs and fees must be fully paid-up front. To move forward with the first steps in the process, please answer the following ELM Financial Responsibility questions.*

I agree to the privacy policy.

Do you currently have an active insurance policy/other?*

Yes

Since you answered yes, please check off all that apply below*

Commercial

Medicaid

Please indicate the state in which your policy was granted

State / Province / Region

Do you understand and agree there is no guarantee that your insurance policy/other will cover any of the ELM services and that you must pay up front.?*

Yes

Do you understand and agree that if your policy may cover some of ELM services you must still first pay up front (and) that it will be your responsibility to work with your insurance/other provider to understand what is covered etc. (and) You will be fully responsible for providing any information or documentation required, claims, etc. by your insurance/other provider?*

Yes

Do you understand and agree that if you have an active health insurance policy/other policy it is your responsibility for keeping it active?*

Yes

Do you understand and agree that if your health insurance policy /policy terminates at any time during this process you are still responsible up front for all costs that may have been reimbursed and are no longer reimbursed by your policy after it terms?*

Yes

Are you in agreement that you are completely responsible up-front for any and all financial costs that are incurred when utilizing the ELM Assessment process and any additional services that may be required for your case?*

Yes

3. Drug and Alcohol Assessment Questions

Is it your goal to obtain and maintain complete abstinence from all drugs and/or alcohol?*

Yes

N/A

Are you willing to be supervised, to strictly follow all instructions and to attend all scheduled appointments?*

Yes

N/A

Are you willing to at minimum, be in constant contact by phone, computer, physical appointment, and/or to wear an alcohol or GPS device in order to prove compliance with any required, ordered, or other agreed upon supervision and/or recommended supervision rules?*

Yes

N/A

Are you willing to comply with all assessment/treatment findings and treatment recommendations in order to improve your total well-being?*

Yes

N/A

Are you willing to authorize and direct our immediate reporting of any perceived infractions, which may result in your immediate collection into police or other custody, to safeguard your health, safety of others, mitigation, and prevention of further potential long term medical/legal problems as a priority over even your freedom and/or short term legal interests?*

Yes

N/A

Are you willing to be assessed (short term, long term, and periodically reassessed if need be) to determine if and to what degree may you have a related substance use disorder problem?*

Yes

N/A

Do you want to receive specific assessment findings that would include treatment/defense recommendations?*

Yes

N/A

Is your goal to end your substance use disorder, by any tools, binding litigation, and/or extended care necessary?*

Yes

N/A

Do you recognize that your health and safety and the health and safety of those around you are more important than your legal status and/or freedom from incarceration?*

Yes

N/A

If you believe you do not have a substance use disorder, are you willing to honestly participate in the assessment process to confirm or determine a professional diagnostic interview and treatment recommendations?*

Yes

N/A

Are you willing to participate in at least one face-to-face one-hour conference with us to further explore your assessment, obtain demographics or other specific information, and any other needed follow up information?*

Yes

N/A

My drug(s) of choice is/are:*

My last date of use was:*

MM slash DD slash YYYY

My most common method(s) of obtaining drugs is/are:*

I am currently on probation.*

Yes

I have had school problems directly or indirectly related to my substance use disorder?*

Yes

I have had family problems directly or indirectly related to my substance use disorder?*

Yes

I have had work problems directly or indirectly related to my substance use disorder?*

Yes

I enjoy gambling on a frequent basis, i.e. scratch-off tickets, lottery, bingo, cards, casino etc...*

Yes

I have been assaulted or assaulted others when under the influence in the past.*

Yes

I am willing to provide a complete medical record, including releases for communication, prior to program involvement.*

Yes

I have or have had significant physical health related issues.*

Yes

People close to me have expressed concern over my substance use.*

Yes

I have had a history of hepatitis a, b, or c.*

Yes

I have past or current issues with chronic pain.*

Yes

Are you currently in a MAT program?*

Yes

Have you previously been part of a MAT program*

Yes

Since you answered yes to "Have you previously been part of a MAT program", please answer the following 3 questions

What were you prescribed?*

For how long and what was the dosage?*

Who prescribed it and did you attend counseling as part of the program?*

Have you seen a mental health professional before? Including therapist, psychiatrist or mental health evaluations.*

Yes

Do you currently identify struggles with depression, anxiety or other mental health issue?*

Yes

I have attempted suicide in the past.*

Yes

I have had recent thoughts of wanting to die or harming myself.*

Yes

Sometimes

Since you answered YES or SOMETIMES to having recent thoughts of wanting to die or harming yourself- Please Specify if there is a plan or level of intent to follow through*

I have an active plan to harm myself.*

Yes

I have had recent thoughts of harming someone else.*

Yes

Sometimes

Since you answered YES or SOMETIMES to having recent thoughts of harming someone else - Please Specify if there is a plan or level of intent to follow through*

Is there any history of significant and traumatic life events; such as deaths, abuse (physical/ emotional/ sexual), accidents, divorce, separation, or other events?*

Yes

Sometimes

Is your substance use disorder also complicated or in any way related to any criminal, civil, family, employment or other legal issue?*

Yes

Are you willing to have our legal counsel regarding above mentioned current charges, divorce proceeding or other professional license issues?*

Yes

If you want our legal counsel what is the next date/or deadline you need to attend/ respond by?*

MM slash DD slash YYYY

4. Questions Regarding Your Career Path

Do you have a vision for your life?*

Yes

Do you have the ability and motivation to work at a job that fits your gifts?*

Yes

Are you willing to set and achieve new goals for your life?*

Yes

Would you be willing to go through a training course to provide you with career direction, soft skills and virtues that employers are demanding?*

Yes

Are you willing to be trained in essential soft skills that can help you in keeping a job?*

Yes

Do you feel you can communicate effectively with others?*

Yes

Do you feel you can work in a team and collaborate with others?*

Yes

Do you feel you can handle conflict in a positive way and do not react to others?*

Yes

Do you have a high confidence level about yourself?*

Yes

Do you feel you are creative?*

Yes

Do you have trouble getting along with people who have a different personality than you?*

Yes

Do you have trouble making decisions?*

Yes

Do you feel you can solve problems easily?*

Yes

Do you feel you manage your time properly?*

Yes

Do you know the behavioral interview process to secure your desired job?*

Yes

Do you feel you could be an entrepreneur (own your own buiness)?*

Yes

Do you lack focus in your life?*

Yes

Do you do your tasks when working with excellence?*

Yes

Would you be willing to be taught the HEROES Virtues of H – Honor, E – Excellence, R – Responsibility, O – Order, E – Expectation, S – Servanthood that will position you for advancement when you are employed?*

Yes

Do you feel like you have the effort and energy to make the necessary changes in your life?*

Yes

5. Complete Checkout Session Below

I understand that I have a continuing obligation to disclose and deliver in written form any changes in answers and circumstances herein.
I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. 4904, relating to unsworn falsification to authorities.
I further agree that any incorrect, misleading, statements, including without limited, failure to immediately supplement and deliver any updates, as well as omissions are agreed by me to be fraudulent and stipulated in advance as admissible and conclusive in any action against me at option of the provider.
It is agreed that this form complies with the H.I.P.A.A. Privacy Rules. In recognition that my on-going health, safety, and welfare and the health, safety, and welfare of those in my immediate environment are one of my most important concerns; and in recognition that those concerns are agreed, to be best provided for by a written, on-going irrevocable direction and waiver this writing confirms SACS/ELM assessing agents and all treatment and defense team members so permitted and directed to share any and all of my information.
Further I hereby irrevocably direct information sharing at all times and waive the electronic transmission and sharing of any and all confidential information as part of this comprehensive, privilege and information waiver at all times unless expressly revoked in written form by myself.
I further direct and authorize SACS/ELM and all agents and all members of the treatment and defense team(s) and future members to continually transmit and share all of my information as they deem necessary, in their sole, absolute and continuing discretion. I further request and direct and permit that all persons or entities SACS/ELM deems necessary, should view any and all confidential and protected medical and legal records or information pertaining to myself.
This direction and authorization includes and extends to all persons, or entities, or organizations associated with SACS/ELM including without limit: legal, medical, psychological, counseling, compliance, enforcement, bond agents, professional and nonprofessionals, family and friends, as well as all specific agents, designees, treatment providers, authorities, legal providers, judiciary, adult probation, defense and prosecuting attorneys, Signature Hill, S.H.P.C., Attorney Angelo Papa as well any other Signature Hill attorney and all of their staff members.
I agree that the waived protected information includes, without limit, any item or items SACS/ELM designees, and agents in their sole discretion further deems necessary including the Assessment Documents, findings, recommendations, behavioral modification contract, prior record, all medical, patient/legal client records, including without limit; inpatient, outpatient and emergency room treatment, clinical charts, progress notes, reports, documents, correspondence, test results, statements, questionnaires/histories, attorney’s and doctor's handwritten notes, and records received by other professionals; all pharmacy/prescription records including NDC numbers and drug information handouts/monographs; all billing records including all statements, itemized bills, and insurance records.
I specifically further authorize, the use of the Internet, e-mail, telephone, conference lines, videoconferencing, digital reproductions, fax, cell phone and any other mode of transmission and storage of information as SACS/ELM and all others and entities designated above, in their sole, absolute, and continuing discretion shall choose to employ, at any time.
I recognize the impossibility of effective, efficient, and least expensive provision of services and a significant related benefit to myself from not only authorizing, but hereby directing SACS/ELM and designees and all others, entities, associates and agents as they choose and deem necessary from time to time, to have continuing sole discretion in all matters related to my file and to carry out all of the provisions of any contracts for services, which contracts and contract paragraphs are hereby incorporated by reference as though fully set forth, and including without limit what is communicated, to whom it is communicated, how often is communicated, and what mode it may be communicated in, including paper, digital, e-mail, attachments, forums, charts, letters, memorandums, faxes, conference calls, telephone conversations, and cell phone conversations.
Any directives, authorizations, waivers in this form or any form are meant to include SACS/ELM and all others and entities, associates and agents as they choose and deem necessary from time to time.
I specify that the scope of what protected and privileged information is permitted to be disclosed is left to the sole, absolute, continuing discretion of SACS/ELM and all others and entities designated above, in their sole and absolute continuing discretion, shall choose to disclose at any time.
This release and authorization includes all files or components of files in any form and all privileges associated with any communications between myself and any of the above-mentioned persons or entities.
I further specify that this release and waiver shall be effective and remain effective until and only if I provide a written specific direction to SACS/ELM by certified mail return receipt requested to 318 Highland Ave., New Castle, Pa. and effective within a reasonable time to be communicated to all other SACS/ELM agents and designees and agents as described above. I further agree to defend, indemnify, and hold harmless SAC/ELM agents and designees from any actions initiated under any of these issues. I further agree to submit any dispute on these issues to binding arbitration, or any other choice of litigation format chosen by SACS/ELM in its sole, continuing, and absolute discretion.
I understand that I have the right to revoke this authorization at any time. I understand that my revocation must be in writing and addressed to the SACS/ELM privacy officer of the above-named and addressed facility authorized to make this disclosure. I understand that the revocation does not apply to information that has already been released in response to this authorization.
It is specifically agreed that if any provision or provisions of this release should for any reason be deemed to be ineffective or otherwise inoperative, it does not affect or in any way eliminate or otherwise render inoperative to the fullest extent the letter and spirit of this document of this release or waiver.
I further recognize that the team treatment concept is a significant benefit to me and that I further agree that in any such circumstance or circumstances, that to the fullest extent possible I agree that there would be no damages, or action for recovery.
I understand that any disclosure of information may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that I need not sign this authorization to assure treatment. I understand that I may inspect and/or copy the information to be disclosed. I understand that authorizing this disclosure is voluntary. I understand that if I have any questions about disclosure of my health or other protected information, I may contact the privacy officer at the facility listed above that is authorized to disclose this information and request a copy of this authorization.
I understand that my health or other protected record may include information pertaining to the treatment of drug and alcohol abuse, mental illness, acquired immunodeficiency syndrome ("AIDS"), or human immunodeficiency virus ("HIV"), sexually transmitted diseases, tuberculosis or genetics.
By checking the appropriate selection, I am evidencing my complete, on-going, knowing, intelligent direction, agreement, and waiver to SACS/ELM and all associates without condition. I have read and agree to the terms and conditions of SACS/ELM and all agents and associates of same.

Consent*

I agree to the privacy policy.

Signature*

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Your Pre-Assessment Screening form will automatically be submitted after your PayPal payment is processed.

IT'S FINALLY POSSIBLE TO PREVENT DRUG & ALCOHOL RELAPSE!

GET TESTED RIGHT NOW BY TAKING A QUICK SURVEY:

Someone claiming they want to
Completely Quit: Pain Meds, Meth, Suboxone?
Truth or Dare!
Dare them to take 15
Minutes and Prove it!

SEE IF YOU OR A LOVED ONE QUALIFIES TODAY

How it Works

Fill Out The Survey

We'll review your qualifications

We'll follow up to discuss your results and get started!

High On Life

SAD Substance

Total Abstinence

Medicine Assisted

SACS 2 Prong

1. Initial Information About You

2. ELM Financial Responsibility, Philosophy, and Policies

3. Drug and Alcohol Assessment Questions

4. Questions Regarding Your Career Path

5. Complete Checkout Session Below

Donate NOW

Subscribe to receive your copy of our ELM Newsletter

Follow Us

© 2022 All Rights Reserved

IT'S FINALLY POSSIBLE TO PREVENT DRUG & ALCOHOL RELAPSE!

GET TESTED RIGHT NOW BY TAKING A QUICK SURVEY:

Someone claiming they want to Completely Quit: Pain Meds, Meth, Suboxone? Truth or Dare! Dare them to take 15 Minutes and Prove it!

SEE IF YOU OR A LOVED ONE QUALIFIES TODAY

How it Works

Fill Out The Survey

We'll review your qualifications

We'll follow up to discuss your results and get started!

High On Life

SAD Substance

Total Abstinence

Medicine Assisted

SACS 2 Prong

1. Initial Information About You

2. ELM Financial Responsibility, Philosophy, and Policies

3. Drug and Alcohol Assessment Questions

4. Questions Regarding Your Career Path

5. Complete Checkout Session Below

Donate NOW

Subscribe to receive your copy of our ELM Newsletter

Follow Us

© 2022 All Rights Reserved

Someone claiming they want to
Completely Quit: Pain Meds, Meth, Suboxone?
Truth or Dare!
Dare them to take 15
Minutes and Prove it!