Kiosk Turning Point of Chittenden County Form | Faces & Voices of Recovery Data Hub

Intake
Please complete the intake form.
Inquiry Date*
MM slash DD slash YYYY
Date Completed*
MM slash DD slash YYYY
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):
MM slash DD slash YYYY
Match Date
MM slash DD slash YYYY
Coach:
First Last
Demographic/Substance Use History/Housing/Employment
Date of Birth:*
MM slash DD slash YYYY
Gender:*
- Male
- Female
- Transgender
- Prefer to Self-Describe
Other Gender
Primary Language:*
- English
- Spanish
- Other
Preferred Pronouns
- She/Her
- He/Him
- They/Them
Orientation:
- Straight
- Lesbian
- Gay
- Bisexual
- Queer
- Other
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:
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
Challenging Substances:*
- Alcohol
- Amphetamines
- Barbiturates
- Benzodiazepines
- Buprenorphine
- Cocaine
- Hallucinogens
- Inhalants
- Marijuana/Cannabis
- Methadone
- Methamphetamine
- Opiates
- None
- Other
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:*
- Own/rent house
- Other’s house
- Own/rent apartment
- Other’s apartment
- Oxford House
- Recovery housing
- Other group housing arrangement
- Hotel/motel
- Place not meant for habitation ( e.g. a vehicle, abandoned building, bus, train, subway station/airport or outside anywhere)
- Shelter
- None
- Other
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:*
- Does not have Insurance
- Private – Employer
- Private- Individual
- Medicare
- Medicaid
- Medicaid and Medicare
- Military Insurance
- State Funded
- State Children’s Health Insurance Program S-CHIP
- Combined Children’s Health Insurance / Medicaid
- Other Public
- Indian Health Services (HIS)
- Don't Know
- Other
- Chose Not to Answer
- County/ Single County Authority
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:
MM slash DD slash YYYY
Recovery Date:
MM slash DD slash YYYY
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*
MM slash DD slash YYYY
Time Recovery Coach Called*

: Hours

Minutes

AM/PM
Start Date of ED Visit*
MM slash DD slash YYYY
Start Time of ED Visit*

: Hours

Minutes

AM/PM
Date of Intake*
MM slash DD slash YYYY
Current Intake Status*
- No Data
- Active
- Inactive
ED RC Log
Contact Date*
MM slash DD slash YYYY
Was Contact Made?*
- Yes
- No
- Hospital Visit
- Admin
Referrals Made*
- Adolescent
- Community Partner
- Detox
- HUB
- Intensive Outpatient
- Outpatient
- Mental Health
- Public Inebriate Program
- Recovery Center
- Residential
- SPOKE
- Support Group
- Women Only
- None

Intake

Demographic/Substance Use History/Housing/Employment

Justice Involvement

Intake Notes & Question Prompts

Emergency Department Intake

ED RC Log