EXIT

Recovery Coach Check-In Tool

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* 1. Peer ID

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* 2. PSP #

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* 3. Intake Date/Time

Date / Time

Date

Time

AM/PM

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* 4. Referral Source

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* 5. Name

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* 6. Phone Number

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* 7. Race/Ethnicity

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* 8. Gender

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* 9. Sexual Orientation

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* 10. For Women only: Reported pregnant?

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* 11. Substance Use

Drugs of Choice?

Days since last alcohol use.

Days since other drugs. Which drugs? How often?

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* 12. Did the Peer agree to a follow up contact?

If yes, list the preferred way to be contacted. Ex- Face-to-face, Phone call

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* 13. Do you already have a Recovery Coach?

If yes, with what organization?

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* 14. Employment Status

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* 15. CURRENT relationship status

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* 16. Currently on parole or probation

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* 17. In the event of arrest or incarceration, would the Peer like to have a PSP follow up in jail/prison?

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* 18. Is the Peer a veteran?

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* 19. Does the Peer have health insurance?

If yes, which type?

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* 20. Drug of Choice?

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* 21. How often, on average, was the main drug of choice recently used?

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* 22. Have you ever been to the ER for an over dose before?

If yes how many times?

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* 23. Placement/ Referral

Placed/ Referred to Detox

Placed/ Referred to Residential

Placed/ Referred to Outpatient

Placed/ Referred to MAT Clinic

Placed/ Referred to Community supports. ie. 12 step, help groups.

Other

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* 24. Do you currently have:

Housing

Transportation

Income

Employment--If yes, Where?

Health Insurance--If yes, What?

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* 25. Satisfaction with current living situation

None

A little bit

Moderatly

Quite a bit

Extremely

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* 26. Do you feel safe in your environment?

At home

At work

Other

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* 27. Do you have access to:

Food

Clothing

Basic supplies for everyday care

Healthcare

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* 28. Have you been in recovery before?--If yes, how many times? Longest amount of time in recovery?

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* 29. What treatment/supports have you tried?

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* 30. Have you ever used Naloxone/Narcan?--If yes, when and by whom?

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* 31. Have you ever used Medically Assisted Treatment (MAT)? If yes, what and when?

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* 32. Would you consider using MAT now?

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* 33. Are you interested in/committed to trying recovery now?

If not now, tell me more

If yes, how can I support you?

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* 34. Reliable Supports

Family Support?--If yes, who?

Sober Friends?--If yes, who?

AA/NA/other recovery group(s)?--If yes, which group(s)?

Sponsor?--If yes, who?

Spirituality/Religion?

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* 35. Mental Health

Do you have any mental health concerns?

Do any family members have any mental health conditions?

Do you feel mental health could have impact on your recovery? Explain.

Mental Health Medications--Current and past.

Mental Health Therapies--Current and past.

Inpatient mental health treatment--If yes, when and where?

Outpatient mental health treatment--If yes, when and where?

Have you ever been in a mental health crisis? If yes, How many? Was it drug related?

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* 36. Physical Health

Do you have any serious physical health conditions you are being treated for?

Physical health medications?--Current and past.

Surgeries?--If yes, when/what for?

Hospitalizations for physical health?--If yes, when/what for?

Chronic health conditions?--If yes, which conditions?

Do you feel like your health care needs are being managed well?--If no, tell us what you would like to change.

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* 37. Legal

Do you have any history with the legal system?

Have you ever had police contact?--If yes, explain.

Have you ever been to jail/prison?--If yes, explain.

Have you/are you on probation?--If yes, explain.

Have you ever been arrested?--If yes, explain.

Do you have any upcoming court dates?--If yes, when/where?

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* 38. Education

Do you have a high school diploma?

Do you have any college education?--If yes, explain.

Do you have any educational goals?--If yes, explain.

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* 39. Goals

What goal can we work on together as peers?

Any goals that you have accomplished since working together?

Any discontinued goals since working together?

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* 1. Peer ID

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* 2. PSP #

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* 3. Intake Date/Time

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* 4. Referral Source

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* 5. Name

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* 6. Phone Number

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* 7. Race/Ethnicity

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* 8. Gender

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* 9. Sexual Orientation

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* 10. For Women only: Reported pregnant?

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* 11. Substance Use

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* 12. Did the Peer agree to a follow up contact?

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* 13. Do you already have a Recovery Coach?

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* 14. Employment Status

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* 15. CURRENT relationship status

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* 16. Currently on parole or probation

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* 17. In the event of arrest or incarceration, would the Peer like to have a PSP follow up in jail/prison?

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* 18. Is the Peer a veteran?

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* 19. Does the Peer have health insurance?

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* 20. Drug of Choice?

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* 21. How often, on average, was the main drug of choice recently used?

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* 22. Have you ever been to the ER for an over dose before?

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* 23. Placement/ Referral

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* 24. Do you currently have:

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* 25. Satisfaction with current living situation

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* 26. Do you feel safe in your environment?

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* 27. Do you have access to:

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* 28. Have you been in recovery before?--If yes, how many times? Longest amount of time in recovery?

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* 29. What treatment/supports have you tried?

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* 30. Have you ever used Naloxone/Narcan?--If yes, when and by whom?

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* 31. Have you ever used Medically Assisted Treatment (MAT)? If yes, what and when?

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* 32. Would you consider using MAT now?

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* 33. Are you interested in/committed to trying recovery now?

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* 34. Reliable Supports

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* 35. Mental Health

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* 36. Physical Health

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* 37. Legal

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* 38. Education

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* 39. Goals

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* 40. Is there anything we missed?