Kiosk Communities for Recovery Spanish

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*

Select All
Coaching Enrollment Form
Informed Consent
Participant Rights
Consent to Check Up
Evaluation Consent
Authorization to Release Information
Identity Residency Income
Media Release Form

Nombre y Apellido	Adulto o Menor (escriba la respuesta completa))	Fecha de Nacimiento	Ingresos (Si o No)	Ingresos brutos de los últimos 30 días	Tipo de Documentación

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Participant Information Form

Substance Use Information

Demographic Information

Healthcare

Substance Use

Mental Health

Legal History

Communication

Forms to be Completed

Formulario de inscripción para participantes de Coaching

Comunidades para la Recuperación Consentimiento informado para Coaching de Recuperación entre Pares

Derechos del Participante

Consentimiento para Proporcionar la Información de Seguimiento

Para la siguiente sección, ingrese NA en cada campo si no corresponde. Para el número de teléfono, ingrese 000-000-0000 si no corresponde. Para correo electrónico, ingrese no@email.com si no corresponde.

Personas adicionales a las que autoriza proporcionar información sobre mi recuperación y ámbitos de vida:

Formulario de Consentimiento de Evaluación

Autorización para Divulgar Información

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

Formulario de Identidad/Residencia/Ingresos

Prueba de Identidad Recibida

Residencia

Miembros e ingresos del hogar

Media Consent & Release Form

Complete los formularios con firma