Contact of Referring OfficerName of Officer Municipality New Burlington County OHH ParticipantName* 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Please enter (000)-000-0000 if you do not have a phone numberHiddenEmail 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 historyPhysical health diagnosis* No Yes Unknown Physical health historySubstance Use HistoryAge 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
