EXIT Recovery Coach Check-In Tool Question Title * 1. Peer ID OK Question Title * 2. PSP # OK Question Title * 3. Intake Date/Time Date / Time Date Time AM/PM - AM PM OK Question Title * 4. Referral Source WF-St. Joseph WF-St. Francis WF-Franklin Other OK Question Title * 5. Name OK Question Title * 6. Phone Number OK Question Title * 7. Race/Ethnicity African American Caucasian Latino/Hispanic Asian Native American More then one race Prefer not to answer Other OK Question Title * 8. Gender Male Female Declined Response OK Question Title * 9. Sexual Orientation Heterosexual Gay Lesbian Bisexual Other OK Question Title * 10. For Women only: Reported pregnant? Yes No Unknown OK Question Title * 11. Substance Use Drugs of Choice? Days since last alcohol use. Days since other drugs. Which drugs? How often? OK Question Title * 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 OK Question Title * 13. Do you already have a Recovery Coach? If yes, with what organization? OK Question Title * 14. Employment Status Full-Time Part-Time Disability Unemployed OK Question Title * 15. CURRENT relationship status Single, not in a relationship Married In a relationship, not living with partner In a relationship, living with partner Other OK Question Title * 16. Currently on parole or probation Yes No OK Question Title * 17. In the event of arrest or incarceration, would the Peer like to have a PSP follow up in jail/prison? Yes No OK Question Title * 18. Is the Peer a veteran? Yes No OK Question Title * 19. Does the Peer have health insurance? If yes, which type? OK Question Title * 20. Drug of Choice? Herion Fentanyl Prescription Opioids Alcohol Marijuana Cocaine Tobacco Other OK Question Title * 21. How often, on average, was the main drug of choice recently used? Daily Almost daily (5-6 times/week) 2-4 times/week Weekly (once/week) 2-3 times/month OK Question Title * 22. Have you ever been to the ER for an over dose before? If yes how many times? OK Question Title * 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 OK Question Title * 24. Do you currently have: Housing Transportation Income Employment--If yes, Where? Health Insurance--If yes, What? OK Question Title * 25. Satisfaction with current living situation None A little bit Moderatly Quite a bit Extremely OK Question Title * 26. Do you feel safe in your environment? At home At work Other OK Question Title * 27. Do you have access to: Food Clothing Basic supplies for everyday care Healthcare OK Question Title * 28. Have you been in recovery before?--If yes, how many times? Longest amount of time in recovery? OK Question Title * 29. What treatment/supports have you tried? OK Question Title * 30. Have you ever used Naloxone/Narcan?--If yes, when and by whom? OK Question Title * 31. Have you ever used Medically Assisted Treatment (MAT)? If yes, what and when? OK Question Title * 32. Would you consider using MAT now? OK Question Title * 33. Are you interested in/committed to trying recovery now? If not now, tell me more If yes, how can I support you? OK Question Title * 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? OK Question Title * 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? OK Question Title * 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. OK Question Title * 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? OK Question Title * 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. OK Question Title * 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? OK Question Title * 40. Is there anything we missed? OK Question Title * 41. Any overdoses OK DONE