Copy of Anonymous Outcomes Survey - First Step Services, LLC

Question Title

* 1. Which type of treatment did you receive at First Step?

Assessment Only

Substance Use

Mental Health

ADETS/Prime for Life

Assessment Only

Substance Use

Mental Health

ADETS/Prime for Life

Question Title

* 2. Since completing treatment at First Step, how would you rate your overall quality of life?

Very Bad

Bad

It's OK

Good

Very Good

Very Bad

Bad

It's OK

Good

Very Good

Other (please specify)

Question Title

* 3. How would you best describe your current employment status?

Full Time

Part Time

Student

Laid Off

Unemployed

Full Time

Part Time

Student

Laid Off

Unemployed

Other (please specify)

Question Title

* 4. Since completing treatment at First Step, how often have you participated in a community mutual-help group such as AA, NA, Smart Recovery, etc?

Never

Daily

Weekly

Monthly

Occasionally

Never

Daily

Weekly

Monthly

Occasionally

Question Title

* 5. Do you consider yourself to be in recovery?

Yes

Question Title

* 6. Since completing treatment at First Step, how many times have you experienced the following due to substance use?

	None	1 Time	2 Times	3 Times
Inpatient Admission	Inpatient Admission None	Inpatient Admission 1 Time	Inpatient Admission 2 Times	Inpatient Admission 3 Times
ER/Hospital Admission	ER/Hospital Admission None	ER/Hospital Admission 1 Time	ER/Hospital Admission 2 Times	ER/Hospital Admission 3 Times
Accidents	Accidents None	Accidents 1 Time	Accidents 2 Times	Accidents 3 Times
Arrests/Incarcerations	Arrests/Incarcerations None	Arrests/Incarcerations 1 Time	Arrests/Incarcerations 2 Times	Arrests/Incarcerations 3 Times

Question Title

* 7. Please indicate in the blanks how often in the past 3 months you have used any of the following substances:

	No Use	1 - 3 x Monthly	1 - 2 x Weekly	3 - 6 x Weekly	Daily
Tobacco	Tobacco No Use	Tobacco 1 - 3 x Monthly	Tobacco 1 - 2 x Weekly	Tobacco 3 - 6 x Weekly	Tobacco Daily
Alcohol	Alcohol No Use	Alcohol 1 - 3 x Monthly	Alcohol 1 - 2 x Weekly	Alcohol 3 - 6 x Weekly	Alcohol Daily
Marijuana or Hash	Marijuana or Hash No Use	Marijuana or Hash 1 - 3 x Monthly	Marijuana or Hash 1 - 2 x Weekly	Marijuana or Hash 3 - 6 x Weekly	Marijuana or Hash Daily
Cocaine or Crack	Cocaine or Crack No Use	Cocaine or Crack 1 - 3 x Monthly	Cocaine or Crack 1 - 2 x Weekly	Cocaine or Crack 3 - 6 x Weekly	Cocaine or Crack Daily
Heroin	Heroin No Use	Heroin 1 - 3 x Monthly	Heroin 1 - 2 x Weekly	Heroin 3 - 6 x Weekly	Heroin Daily
Hallucinogens	Hallucinogens No Use	Hallucinogens 1 - 3 x Monthly	Hallucinogens 1 - 2 x Weekly	Hallucinogens 3 - 6 x Weekly	Hallucinogens Daily
Benzodiazepines (non-prescribed) (Le. Valium, Xanax, Klonopin)	Benzodiazepines (non-prescribed) (Le. Valium, Xanax, Klonopin) No Use	Benzodiazepines (non-prescribed) (Le. Valium, Xanax, Klonopin) 1 - 3 x Monthly	Benzodiazepines (non-prescribed) (Le. Valium, Xanax, Klonopin) 1 - 2 x Weekly	Benzodiazepines (non-prescribed) (Le. Valium, Xanax, Klonopin) 3 - 6 x Weekly	Benzodiazepines (non-prescribed) (Le. Valium, Xanax, Klonopin) Daily
Opioids (non-prescribed) (i.e. Oxycodone, Hydrocodone)	Opioids (non-prescribed) (i.e. Oxycodone, Hydrocodone) No Use	Opioids (non-prescribed) (i.e. Oxycodone, Hydrocodone) 1 - 3 x Monthly	Opioids (non-prescribed) (i.e. Oxycodone, Hydrocodone) 1 - 2 x Weekly	Opioids (non-prescribed) (i.e. Oxycodone, Hydrocodone) 3 - 6 x Weekly	Opioids (non-prescribed) (i.e. Oxycodone, Hydrocodone) Daily
Stimulants (non-prescribed) (Le. Ritalin, Adderall)	Stimulants (non-prescribed) (Le. Ritalin, Adderall) No Use	Stimulants (non-prescribed) (Le. Ritalin, Adderall) 1 - 3 x Monthly	Stimulants (non-prescribed) (Le. Ritalin, Adderall) 1 - 2 x Weekly	Stimulants (non-prescribed) (Le. Ritalin, Adderall) 3 - 6 x Weekly	Stimulants (non-prescribed) (Le. Ritalin, Adderall) Daily
Inhalants	Inhalants No Use	Inhalants 1 - 3 x Monthly	Inhalants 1 - 2 x Weekly	Inhalants 3 - 6 x Weekly	Inhalants Daily
Methamphetamine	Methamphetamine No Use	Methamphetamine 1 - 3 x Monthly	Methamphetamine 1 - 2 x Weekly	Methamphetamine 3 - 6 x Weekly	Methamphetamine Daily
Kratom	Kratom No Use	Kratom 1 - 3 x Monthly	Kratom 1 - 2 x Weekly	Kratom 3 - 6 x Weekly	Kratom Daily

Other (please specify)

Question Title

* 8. Which best describes your current living situation?

Independent (own home/apartment/dorm)

Living with relatives/parents

Sober living home

Residential Facility (half-way house/group home/therapeutic community)

Homeless (shelter/vehicle/place-to-place)

Hospital

Correctional Facility

Other (please specify)

Question Title

* 9. Overall, how helpful was the treatment experience at First Step?

Not Helpful At All

Not Helpful

Neither Helpful or Unhelpful

Helpful

Very Helpful

Not Helpful At All

Not Helpful

Neither Helpful or Unhelpful

Helpful

Very Helpful

Other (please specify)

Copy of Anonymous Outcomes Survey - First Step Services, LLC

Question Title

* 1. Which type of treatment did you receive at First Step?

Question Title

* 2. Since completing treatment at First Step, how would you rate your overall quality of life?

Question Title

* 3. How would you best describe your current employment status?

Question Title

* 4. Since completing treatment at First Step, how often have you participated in a community mutual-help group such as AA, NA, Smart Recovery, etc?

Question Title

* 5. Do you consider yourself to be in recovery?

Question Title

* 6. Since completing treatment at First Step, how many times have you experienced the following due to substance use?

Question Title

* 7. Please indicate in the blanks how often in the past 3 months you have used any of the following substances:

Question Title

* 8. Which best describes your current living situation?

Question Title

* 9. Overall, how helpful was the treatment experience at First Step?

Question Title

* 10. Please tell us how First Step can improve its services, or if you have any additional comments that would help us to better serve.