New Participant + Intake

New Participant + Intake One

Program Site*
Program*
BSCC Grant Affiliated?
- No
- Yes
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone
Home Zip Code*
Email*
Enter Email Confirm Email
Contact Preference
Best Time of Day to Contact*
HIPAA Release
Date*
MM slash DD slash YYYY
I hereby authorize Young People in Recovery and its affiliates, its employees and agents to collect my personal health information maintained by the referral site selected below (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address) except the following information about me:
I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws. This authorization is valid from the date of my/my representative’s signature below. I understand that I have a right to revoke this authorization by providing written notice to Young People in Recovery. However, this authorization may not be revoked if Young People in Recovery, it’s employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. I understand that YPR will be following up with me at 3, 6, and 12 months after completion of the program. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.
HIPAA Consent*
- I have read, understand and consent to the release of information.
Additional information on my rights can be found here.
Evaluation Consent
Evaluation Consent*
- I understand all of the following information and consent to evaluation.
Young People in Recovery has explained the evaluation to you and answered all of your questions. You have been told the possible benefits and the potential risks and/or discomforts of the evaluation. You understand that you do not have to take part in this evaluation, and your refusal to participate or your decision to withdraw will involve no penalty or loss of rights or benefits. The evaluation personnel may choose to stop your participation at any time. You understand why the evaluation is being conducted and how it will be performed. You understand your rights as a evaluation participant and you voluntarily consent to participate in this evaluation. You have been told you will receive a copy of this form.
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Participant Info
Demographic Data
Gender*
Other Gender
Ethnicity*
Race*
If Mixed Race, Select All that Apply.
If Not Listed, Please Describe Above
Sexual Orientation*
Do you consider yourself to be someone living with:*
If Multiple Impairments or Other, please describe.
Veteran Status*
Have you ever received NARCAN or Naloxone?*
Have you recently been released from a correctional facility?*
Have you been in a controlled environment in the past 6 months?*
A controlled environment can include, but is not limited to, jail, alcohol/drug treatment, medical treatment, etc.
How many days have you stayed overnight in a hospital for medical problems in the past 6 months (if any)?*
Please enter a number from 0 to 180.
(Include O.D.’s and D.T.’s. Exclude detox, alcohol/drug and psychiatric hospitalization, and childbirth (if no complications) Enter the number of overnight hospitalization for medical problems). Enter 0 as a value if the client has not stayed overnight in a hospital in the past 6 months.
How many days have you stayed overnight in a hospital for psychiatric problems in the past 6 months (if any)?*
Please enter a number less than or equal to 180.
Enter 0 as a value if you have not stayed overnight in a hospital in the past 6 months.
How many days have you attended peer-support groups in the past 6 months (if any)?*
Please enter a number from 0 to 180.
Peer support groups can include, but are not limited to, NA, AA, CA, All Recovery Meetings, Smart Recovery, Life Ring, Women for Sobriety and Celebrate Recovery.
How many times have you visited an Emergency Room in the past 6 months (if any)?*
Please enter a number greater than or equal to 0.
Are you pregnant at time of admission?*
How many children do you have, aged 17 or less (birth or adopted) - whether they live with you or not (if any)?*
Please enter a number greater than or equal to 0.
Employment Status*
Are you currently enrolled in school?*
Highest level of education attained*
Vocational. training, or education programs
- I have been enrolled in vocational. training, or education program in the past 6 months
How many times have you been arrested in the past 6 months (if any)?*
Please enter a number greater than or equal to 0.
Arrested means taken into police station and fingerprinted.
Have you ever been charged for behavior associated with substance use?*
- Yes
- No
If so, were you convicted?
- Yes
- No
- Case Pending
How many convictions have you faced due to substance use related challenges?*
Please enter a number greater than or equal to 0.
Were the convictions you faced deemed to be a felony or misdemeanor?*
- Felony
- Misdemeanor
- Both
- Not applicable
Living Arrangements*
Primary Substance Used*
Frequency of Use*
Primary Route of Administration*
Baseline

Importance*

	Not important at all	Not very important	Neutral	Important	Very important
How important is it for people to have good leadership skills in recovery?
How important is it for people to know how to pursue education in their recovery?
How important is it for people to know how to find employment in recovery?
How important is it for people to have access to adequate housing in recovery?
How important is it for people to understand financial responsibility in their recovery?
How important is it for people to feel empowered in their recovery?
How important is it for people to understand their legal rights in recovery?

Participation in Life Skills Class
- I've participated in Life Skills Classes before
Prior Participation in Leadership Class
- I've had prior participation in Leadership Classes before

Preparedness*

	Not prepared at all	Not very prepared	Neutral	Somewhat prepared	Very Prepared
How would you rate your preparedness around pursuing Education?
How would you rate your preparedness around attaining Employment?
How would you rate your preparedness around attaining Housing?
How would you rate your preparedness around handling Finances?

How would you rate your leadership skills?*
How would you rate your current dedication to your recovery?*
How would you rate your current feeling of empowerment?*
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How would you rate your current understanding of your legal rights as a person in recovery?*
How would you rate your current understanding of finances?*
How confident do you feel in your ability to build and maintain healthy relationships?*
How confident do you feel in your ability to build and maintain a healthy physical, spiritual, and mental lifestyle?*
How confident are you in your ability to explain the neuroscience of substance use disorder to someone with no knowledge of the subject?*
Assessment of Recovery Capital
I am currently completely abstinent from substance use*
I feel I am in control of my substance use*
I have had no thoughts about reoccurrence*
I have had no recent periods of substance intoxication*
There are more important things to me in life than using substances*
I am able to concentrate when I need to*
I am coping with the stresses in my life*
I am happy with my appearance*
In general I am happy with my life*
What happens to me in the future mostly depends on me*
I cope well with everyday tasks*
I feel physically well enough to work*
I have enough energy to complete the tasks I set myself*
I have no problems getting around*
I sleep well most nights*
I am proud of the community I live in and feel part of it*
It is important for me to contribute to society and or be in involved in activities that contribute to my community*
It is important for me that I make a contribution to society*
It is important for me to do what I can to help other people*
My personal identity does not revolve around drug use or drinking*
I am happy with my personal life*
I get lots of support from friends*
I am satisfied with my involvement with my family*
I get the emotional help and support I need from my family*
I have a special person that I can share my joys and sorrows with*
I am actively involved in leisure and sport activities*
I am actively engaged in efforts to improve myself (training, education and/or self-awareness)*
I engage in activities that I find enjoyable and fulfilling*
I have access to opportunities for career development (job opportunities, volunteering or apprenticeships)*
I regard my life as challenging and fulfilling without the need for using drugs or alcohol*
I am proud of my home*
I am free of threat or harm when I am at home*
I feel safe and protected where I live*
I feel that I am free to shape my own destiny*
My living space has helped to drive my recovery journey*
I am free from worries about money*
I have the personal resources I need to make decisions about my future*
I have the privacy I need*
I make sure I do nothing that hurts or damages other people*
I take full responsibility for my actions*
I am happy dealing with a range of professional people*
I do not let other people down*
I eat regularly and have a balanced diet*
I look after my health and wellbeing*
I meet all of my obligations promptly*
Having a sense of purpose in life is important to my recovery journey*
I am making good progress on my recovery journey*
I engage in activities and events that support my recovery*
I have a network of people I can rely on to support my recovery*
When I think of the future I feel optimistic*
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New Participant + Intake

New Participant + Intake One

HIPAA Release

Evaluation Consent

Participant Info

Demographic Data

Baseline

Assessment of Recovery Capital

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Alaskan Native
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Asian Indian
Black or African American
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Chinese
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Mixed Race
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Not Listed
Other Asian
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Samoan
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White