Application for Services
Please complete this form if your organization in interested is hosting an Ideal Option satellite kiosk for medication-assisted treatment services. Please note services are only available in WA, OR, ID, MT, NM, MN, MD, ND and AR.
Organization Name
Services Provided
Contact Name
First Name
Last Name
Contact Email
example@example.com
Organization Address
Street Address
Street Address Line 2
City
State
Zip Code
Please tell us why you are interested in offering onsite MAT services.
How many individuals would you estimate are in need of MAT services at your organization?
10 - 20
20 - 30
30 - 40
50+
Other
Please respond to the following questions:
YES
NO
UNSURE
Do you have a private room available?
Is there an ADA restroom available?
Are you able to collect urine specimens?
Can you accommodate a lockbox for specimens?
Do you have wi-fi strong enough for video calls?
Do you have a computer workstation available?
Is your building zoned for medical use?
Can you verify patient insurance coverage?
Can your staff assist with patient intake?
Is there anything else you'd like to share with us?
Submit
Should be Empty: