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* 1. ID Code

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* 2. PSP #:

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* 3. Date

Date
Time

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* 4. Referral Source

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* 5. Contact Type

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* 6. Time Spent

 
In Minutes

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* 7. Did the Peer agree to a follow-up contact

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* 8. Phone Number
*** supervisors must redact this information before this form is submitted***

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* 9. Name
*** supervisors must redact this information before this form is submitted***

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* 10. Do you already have a recovery coach?

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* 11. Intake assessment not completed during the initial contact:

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* 12. Age

 
In Years

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* 13. Gender

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* 14. Sexual orientation:

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* 15. For women only: reported pregnancy

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* 16. Race/Ethnicity (mark all that apply)

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* 17. Employment status:

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* 18. CURRENT relationship status (choose one):

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* 19. Currently on a parole or probation

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

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* 21. Is the Peer a veteran?

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* 22. Does the Peer have health insurance

 
Choose

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* 23. What is the Peer's CURRENT Main drug of choice? (select ONE)

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* 24. How often, on average in the PAST MONTH, has the Peer used main drug of choice?

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* 25. At what age did the Peer start using alcohol or drugs REGULARLY

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* 26. What substances has the Peer REGULARLY used in their lifetime ? Select all that apply.

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* 27. Total number of overdoses (including this current one, if applicable) in lifetime?

 
Choose

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* 28. Total number of overdoses (including this current one, if applicable) in the past month?

 
Choose

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* 29. If yes to an overdose, is this current contact with PSP due to an overdose?

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* 30. What drugs does the Peer think caused the most recent overdose? (select all that apply)

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* 31. Of the past month overdoses, how many:

 
Were attended by first responders (e.g., EMS, police, firefighter)? ________
Resulted in a hospital or ED visit?
Resulted in the use of naloxone by the Peer or family member or friend

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* 32. Has the Peer ever received treatment for addiction?

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* 33. If YES, specify for what substances (check all that apply)

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* 34. If YES, what types of treatment did the Peer received to date? (select all that apply)

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* 35. If YES, how long ago was the last treatment for addiction? (select one)

 
Last treatment was how long ago
It is current (ongoing)

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* 36. Does it include MAT for opioid addiction?  If yes, which MAT does it include? (choose one)

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* 37. Has the Peer ever been treated for mental health problems (Other than addiction). Including counseling ? (SELECT ONE)

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* 38. If YES, specify for what mental health problems (check all that apply)

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* 39. If YES, how long ago was the last treatment for mental health problems? (select one)

 
Last treatment was how long ago
It is current (ongoing)

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* 40. Has the Peer EVER been engaged in recovery support services 
(SELECT ALL THAT APPLY):

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* 41. If yes, is the Peer engaged in the recovery support services NOW?
If yes, what types of recovery support services is the Peer engaged in now?

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* 42. Current housing situation?

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* 43. Is the current living situation supportive for recovery?

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* 44. Does the Peer feel safe in his/her current living situation?

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* 45. Does the Peer currently need help with:

 
Employment
Food
Clothing
Daily care items
Transportation
Declined Response
Unknown

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* 46. Does the Peer have social support which is supportive for recovery? (Select all that apply)

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* 47. At this time, what are the Peer's main barriers to recovery?

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* 48. At this time, does the Peer have any goals they wish to work toward? 
(ASK PEER DIRECTLY)

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* 49. ASK PEER DIRECTLY:
On a scale from 0=Strongly Disagree to 10=Strongly Agree.
How would you rate your current feelings about the following statement:
My recovery is the most important thing in my life.

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* 50. ASK PEER DIRECTLY: 
On a scale from 0=Very Poor to 10=Very Good.
How would you rate the overall quality of your life today?

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* 51. Is there anything we missed?

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0 of 51 answered
 

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