REFERRAL FORM

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Please select  any of the following that are true - at any point in your lifetime:

1 .  A history of opioid use disorder (OUD) or history of opioid use/misuse .

2.  A history of stimulant use disorder or history of stimulant use/misuse .

3.   A history of opiate-related overdose 

4.  None 

Please select  any of the following that are true - at any point in your lifetime:

1 .  A history of opioid use disorder (OUD) or history of opioid use/misuse .

2.  A history of stimulant use disorder or history of stimulant use/misuse .

3.   A history of opiate-related overdose 

4.  None