Kiosk Communities for Recovery Form

Participant Name*

First Last

Auto Number*

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Status

I am only completing forms

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My Program is:*

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Participant Information Form

Please create your new participant record.

Date of Birth*

Home Address*

If current address does not exist please use NA

Street Address Address Line 2 City State ZIP Code

Phone*

Please enter (000)-000-0000 if you do not have a phone number

Email*

If you don't have an email address, please input "no@email.com".

Emergency Contact

First Last

Emergency Contact Phone

Relationship to Emergency Contact

Relationship to Emergency Contact, if Other

Relationship Status

How did you hear about us?*

Friend/Family
Treatment Provider
Probation officer
Emergency Department

Recovery Date

Form of Transportation

Has a reliable car
Relies on others
Uses public transportation

Reason for Referral

Reason for Referral, if Other

Substance Use Information

Please select any that apply

Substances Used in the Last 30 Days

Challenging Substances

Demographic Information

Gender (Select all that apply):*

Male
Female
Nonbinary
Transgender
Prefer to Self-describe

Gender, if Other

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

Race, if Other

Ethnicity

Hispanic
Not Hispanic
Other

Ethnicity, if Other

Are you a veteran?

Yes
No

Orientation

Orientation, if Other

Employment Status

Working full or part time
Unemployed and looking for work
Not employed and not looking for work
On disability
Student
Retired
Don't Know
Refused
Other

Employment Status, if Other

Housing/Shelter

Healthcare

Insurance

No Insurance
Medicaid
Medicare
Veterans Administration
MAP/County
Private Insurance (Employer)
Private Insurance (Individual)

How would you rate your physical health?

Are you experiencing any physical pain right now?

Yes
No

If so, how high would you rate this on a scale of 1-10 (with 10 being most painful)?

Do you feel you have any health concerns that need to be addressed?

Yes
No

Substance Use

Have you Been to treatment?

Yes
No
Refused

Treatment Services in the last 30 days

Check all that apply.

Treatment Services in the last Year

Mental Health

How would you rate your mental health?

Do you consider yourself having issues or concerns with your mental health?

Yes
No
Choose not to disclose

Have you received treatment for a mental health related issue?

Yes
No

If yes, please indicate type of services:

Psychiatrist/Medical Doctor
Therapist/Counselor
Case Manager
Crisis Worker

Are you having thoughts of harming yourself or others?

Yes
No

If so, do you intend to harm yourself or others?

Yes
No

Legal History

Do you currently have criminal justice involvement?

Yes
No
Choose not to disclose

Are you currently on probation/parole?

Yes
No
Refused

Communication

In addition to face to face communication, I agree that Communities for Recovery may communicate with me using the following methods. I understand that these methods of communication may not be confidential and can be intercepted and possibly read or heard by other people.

Communication Consent*

Please check all that apply.

None
Phone
Text
Fax
Mail
Email

Consent*

I hereby acknowledge receipt of the Participant Information form.

Forms to be Completed

Please select which form(s) need to be completed.

Forms to be Completed*

Household Member First and Last Name	Adult or Minor (type full response)	Date of Birth (please enter as xx/xx/xxxx	Income (Yes or No)	Gross Income of Last 30 days ($ amount)	Documentation Type (from list below. If other, please specify)

Step 1 of 11

Participant Information Form

Substance Use Information

Demographic Information

Healthcare

Substance Use

Mental Health

Legal History

Communication

Forms to be Completed

Peer Recovery Support Participant Enrollment Form

Peer Recovery Support Services Informed Consent

Participant Rights

Consent to Provide Checkup Information

For the section below, please enter NA in each field if it is not applicable. For phone number, enter 000-000-0000 if not applicable. For email, enter no@email.com if not applicable.

Evaluation Consent Form

Authorization to Release Information

Austin / Travis County Homeless Management Information System Data Sharing Policy and Release of Information (ROI)

Identity/Residency/Income Form

Proof of Identity

Residency

Household Members and Household Income

Media Consent & Release Form

Complete Forms with Signature