Registration for Coping with Change Group Survey

Thank you for your interest in CODAC's Coping With Change Group. This virtual Zoom support and skills group is available to current CODAC members on Mondays from 2:30-3:30pm (starting 9/14/20).

To register, please complete the entire form below. You will get a call or email from CODAC with the Zoom Meeting ID so you can join the group!

Question Title

* Contact Information

First Name

Last Name

Date of Birth

Email Address

Cell Phone Number

Question Title

* I am a current CODAC member/client/patient.

Yes

Question Title

* This group requires that you are able to use Zoom video conferencing.

I can use Zoom.

I can not use Zoom.

Question Title

* Are you currently having any of the following:

Suicidal thoughts.

Hallucinations.

Chronic or ongoing drug or alcohol use.

None of the above.

In the questions below, please tell us about a variety of areas that might be causing you problems in your life. Your answers are confidential and will help us prepare for your Coping with Change group.

Question Title

* Do you have any concerns about your own or a family member's physical health? (Describe)

Question Title

* How important are these concerns about physical health to you?

Urgent

Important but not urgent

Not important

Other (please specify)

Question Title

* Do you have any concerns about how you or a family member are coping emotionally? (Describe)

Question Title

* How important are these concerns about your emotional health to you?

Urgent

Important but not urgent

Not important

Other (please specify)

Question Title

* Do you have any concerns for your own or your family's safety right now or in the future? (Describe)

Question Title

* How important are these concerns about your safety to you?

Urgent

Important but not urgent

Not important

Other (please specify)

Question Title

* Do you have concerns about meeting the basic necessities of daily life? (Describe)

Question Title

* How important are these concerns about your basic needs to you?

Urgent

Important but not urgent

Not important

Other (please specify)

Question Title

* Do you have any concerns about your own or a family member's use of alcohol, drugs, or prescription medications? (Describe)

Question Title

* How important are these concerns about substance use to you?

Urgent

Important but not urgent

Not important

Other (please specify)

Question Title

* Do you have any concerns about how well you are functioning in your daily life at home, work or school? (Describe)

Question Title

* How important are these concerns about your ability to function to you?

Urgent

Important but not urgent

Not important

Other (please specify)

Question Title

* Do you have any concerns about how you are getting along with people - your spouse/partner, family members, neighbors, friends, or people at work or school? (Describe)

Question Title

* How important are these concerns about your interpersonal life to you?

Urgent

Important but not urgent

Not important

Other (please specify)

Question Title

* Is there anything else that you are concerned about or want to share with us? (Describe)

Question Title

* How important are these other concerns to you?

Urgent

Important but not urgent

Not important

Other (please specify)

Thank you!

Please note: This group may not be appropriate for some members/individuals depending on their current recovery goals. The group leaders have the right to refer members/individuals to more appropriate services.