BCFS00710-MMTC-Fishman-OUD [Screening Form

Screening Form

Do you have a loved one who is a young adult and struggling with opioids? We have a free clinical program for concerned significant others of young people ages 18-26 with opioid addiction. The program provides support and practical tools for you, and ultimately tries to connect your loved one to evidence based treatment. If you're interested in learning more, please fill out the screening form below.

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First Name

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Last Name

Phone Number

Email Address

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Gender

Male

Female

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Date of Birth

Do you know someone who might have opioid use disorder (OUD)?

Yes

Is your loved one aged 30 years or younger?

Yes

N/A- I do not have a loved one with OUD

Is your loved one currently in stable treatment or in the process of recovery from opioid use disorder?

Yes

N/A- I do not have a loved one with OUD

Are you interested in getting help for your loved one who might have opioid use disorder (OUD)?

Yes

N/A- I do not have a loved one with OUD

Do you live in Maryland?

Yes

Are you age 21 or older?

Yes

What category best describes you?

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino, or Spanish origin

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

What is your preferred contact method?

Phone call

Text

What is the best time for a study team member to reach out to you?

Mornings (8:00am-11:00am)

Early afternoons (11:00am-2:00pm)

Afternoons (2:00pm-5:00pm)

Evenings (5:00pm-8:00pm)

You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.

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