Alcohol Use Statement Form - PursueCare

A new version of the PursueCare app is available.
Download now!

Alcohol Use Statement Form

Please read the text below then sign at the bottom.

  • I understand that the use of alcohol can be damaging, and even deadly when used in combination with Suboxone/Buprenorphine. I have been counseled on the need to abstain from alcohol and understand that significant risks can occur if I continue to use both.

    These risks can include:

    • Breathing problems
    • Confusion and damage to the central nervous system and peripheral nervous system
    • Malnutrition
    • Chronic pancreatitis and/or alcoholic liver disease
    • Cancer
    • Various injuries
    • Heart disease and/or stroke
    • Depression and sleep disorders
    • Bleeding from the stomach
    • Birth defects
    • Increased risk of side effects from the Suboxone/Buprenorphine medication
    • Increased risk of physical dependence from both substances

    Methods to help to decrease and/or stop alcohol use include:

    • Keeping track/keeping a diary of how much you drink
    • Counting and measuring your alcohol consumption
    • Setting goals
    • Avoiding triggers
    • Seeking professional help, which can include medications to aid with preventing relapse
    • Counseling
    • Utilizing professional mental health treatment if anxiety or depression are contributing to your alcohol use
    • Attending Alcoholics Anonymous or similar groups

    I acknowledge that I have been counseled on the need to refrain from alcohol use. I understand that if I continue to use alcohol that I am at considerable risks of health issues including death. I understand that I would benefit from additional treatment for alcohol use, and I understand that I can receive additional assistance with a referral for alcohol treatment.

  • Date Format: MM slash DD slash YYYY