Burlington OHH - Faces & Voices of Recovery Data Hub

Contact of Referring Officer
Name of Officer
Municipality
New Burlington County OHH Participant
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender (select all that apply)*
- Male
- Female
- Nonbinary
- Transgender
- Prefer to Self-describe
Gender:
Is Participant pregnant?*
- Yes
- No
- Don't know
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Please enter (000)-000-0000 if you do not have a phone number
This field is hidden when viewing the form
Email

If you don't have an email address, please input "no@email.com".
Primary Health Insurance*
- Private
- Medicaid
- Medicare
- Tricare
- Uninsured
OHH Program Type*
- Arrest
- Non-Arrest
- Court Outreach/Diversion
Veteran Status*
- Veteran
- Not a Veteran
Does participant have access to transportation?*
- Yes
- No
Type of Identification
Race*
- White
- Hispanic, Latino, or Spanish Origin
- Black or African American
- Middle Eastern or North African
- American Indian or Alaska Native –
- Asian –Native Hawaiian or Other Pacific Islander
- More than one race
- Other
Other Race:
Ethnicity*
- Hispanic
- Not Hispanic
- Other
Other Ethnicity:
Employment Status:*
- Working full or part time
- Unemployed and looking for work
- Not employed and not looking for work
- Other
Other Employment
Housing Status:*
- Own/rent house
- Own/rent apartment
- Homeless
- Other
Mental health diagnosis*
- No
- Yes
- Unknown
Mental health history
Physical health diagnosis*
- No
- Yes
- Unknown
Physical health history
Substance Use History
Age of Onset*
Please enter a number from 0 to 99.
Substances used at Onset
- Alcohol
- Benzodiazepines
- Cocaine/Crack
- Fentanyl
- Hallucinogens/psychedelics
- Heroin
- Kratom
- Marijuana
- Methamphetamine
- None
- Non-prescription methadone
- Other
- Other amphetamines
- Other prescription opioids
- Synthetic Cannabis
- Tobacco/Nicotine Product
Drug(s) currently using
- Alcohol
- Benzodiazepines
- Cocaine/Crack
- Fentanyl
- Hallucinogens/psychedelics
- Heroin
- Marijuana
- Methamphetamine
- Non-prescription methadone
- Other amphetamines
- Other prescription opioids
- Other
- Tobacco/Nicotine Product
- None
Challenging Substances:*
- Alcohol
- Benzodiazepines
- Cocaine/Crack
- Fentanyl
- Hallucinogens/psychedelics
- Heroin
- Kratom
- Marijuana
- Methamphetamine
- None
- Non-prescription methadone
- Other
- Other amphetamines
- Other prescription opioids
- Synthetic Cannabis
- Tobacco/Nicotine Product
Has the participant ever overdosed?*
- No
- Yes
- Unknown
Prior substance use treatment?*
- Inpatient/Hospital
- Intensive Outpatient Program
- MAT using methadone
- MAT using buprenorphine
- MAT using naltrexone
- MAT using other medication
- Outpatient Counseling
- Partial Hospitalization Program (PHP)
- Residential Treatment
- Withdrawal/detox management
- Other (describe)
- None
Times treatment has been tried?*
Please enter a number from 0 to 99.
Treatment services offered*
- Inpatient care
- Residential treatment
- Intense outpatient program
- MAT
- Recovery Specialist
Treatment services declined*
- Inpatient care
- Residential treatment
- Intense outpatient program
- MAT
- Recovery Specialist
- None
Why were Services Declined?
The purpose of the disclosure authorized in this consent is to receive recovery support. I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 160 &164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time. I understand and agree to the following: 1. I grant permission for a volunteer to call me at the above phone number, email, and/or address to support me in my recovery. 2. Each time the volunteer calls, he/she will be asking me how my recovery is progressing and if I am in need of additional support (i.e., meetings in area, recovery community centers, safe/sober housing, social events, other resources). 3. At the time of the call, if I am in need of a referral to a treatment program or detox unit, I will be assisted in finding a program, if I so desire. 4. If at any time I decide not to take part in this program, I will contact the center or tell the volunteer when he/she calls.
Consent
I agree to the above