Kiosk Turning Point of Chittenden County Form

Intake

Please complete the intake form.

Program*

Please select the program this intake is for.

Inquiry Date*

Date Completed*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

If you do not have an address, please enter 000 Main Street.

Phone*

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

Approved forms of contact:

Text
Message
Both
Neither

Email*

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

Participant ID:

What do you know about recovery coaching?

Informed Consent

Explanation: Information given to the Turning Point Center of Chittenden County is for data collection and helps us to secure funding for the Recovery Coaching Program. This information is confidential, your name and any other identifiers will not be shared with any outside person or agency without your written consent.

Yes
No

How did you hear about Recovery Coaching?*

Residential Treatment
E.D./Hospital
Therapist/Counsellor
Treatment Court
Recovery Center
Probation & Parole
Primary Care Provider

Intake SSM?

Yes
No

Date (Intake SSM):

Match Date

Coach:

First Last

Demographic/Substance Use History/Housing/Employment

Date of Birth:*

Gender:*

Male
Female
Transgender
Prefer to Self-Describe

Other Gender

Primary Language:*

English
Spanish
Other

Preferred Pronouns

She/Her
He/Him
They/Them

Orientation:

Other Orientation:

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
Unknown
Other

Other Ethnicity:

What is your primary substance of challenge?*

Challenging Substances:*

Substance Use Medications for Treatment:

MAT using methadone
MAT using buprenorphine
MAT using naltrexone
MAT using other medication

Are you currently receiving mental health counseling?

Yes
No
Refused

Housing Status:*

Highest Level of Education:

Less than HS
HS grad/GED
Some college
Technical School/2-yr degree
4-yr degree (BS/BA)
Graduate degree (Masters or doctorate)
Don't Know
Refused
Not Applicable

What is your 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

Do you have health insurance?*

Yes
No

Type of primary insurance:*

Are you a veteran?

Yes
No

Justice Involvement

Have you ever had criminal justice involvement (such as been arrested or detained)?

Yes
No

Are you currently on probation or parole?

Yes
No

Are you currently on probation or parole?*

Yes
No

Have you been arrested in the past 30 days?

Yes
No

Have you been arrested in the past 30 days?*

Yes
No

Number of times arrested in the past 30 days*

Are you currently awaiting charges, trial, or sentencing?

Yes
No
Refused

Do you currently participate in a drug court program or are you in a deferred prosecution agreement?

Drug Court Program
Deferred Prosecution Agreement
Neither
Refused

Intake Notes & Question Prompts

What support groups are you using, or might you be interested in?

AA
NA
Refuge Recovery
SMART Recovery
All Recovery
Other Support Group
None

Other Support Group(s):

In what area do you feel you need the most immediate support?

Housing
Employment
Basic Needs Services
Mental Health
Relationships/Connections
Addiction Recovery/Recovery from SUD
Other

Other Area for Support:

Last time you used:

Recovery Date:

Do you have preferences for a Recovery Coach?

Male
Female
Either
Phone
In Person
Zoom

What else would you wish for your Recovery Coach to know before your first session? Are you presently at risk?

Emergency Department Intake

Hospital*

UVMMC

Referring Physician Name*

Date Recovery Coach Called*

Time Recovery Coach Called*

:

Start Date of ED Visit*

Start Time of ED Visit*

:

Reason for ED Visit*

Other Reason for ED Visit*

Date of Intake*

Current Intake Status*

No Data
Active
Inactive

ED RC Log

Contact Date*

Was Contact Made?*

Yes
No
Hospital Visit
Admin

Referrals Made*