RCCF1 Form - Faces & Voices of Recovery Data Hub

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Section Break
Check-In/Drop-In/First Time Visit
If you are attending a recovery group, event, center resource, or training, select Check-In. If you are here to see your Recovery Coach, select Drop-In.
Site*
Request Contact
Please provide the following information and we will get back to you shortly.
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Section Break
Are you:*
- Checking-In
- Dropping-In (Existing Member)
- First Time Visit
Would you like to remain Anonymous?*
- Yes
- No
Name*
First Last
Have you registered as a Member of our Center?*
- Yes
- No
Your Participant Short Code:*
Your participant short code is your first initial, last initial, birth month, day and year in the following format: FL10211901 Where First Last's birth date is 10/21/1901.
I am anonymously attending*
- Recovery Group
- Recovery Special Event
- Center Resource
Non-Participants can not check in for one-on-one sessions.
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I am attending-*
- Recovery Group
- Recovery Special Event
- Center Resource
Please fill our New Member form below if you are not a member! OR change to check-in anonymously.
I am attending:*
- Recovery Group
- Recovery Special Event
- Recovery Support Services
- Center Resource
- Training
Please fill our New Member form below if you are not a member! OR change to check-in anonymously.
Recovery Group*
- AA
- AA (Beginners)
- AA (Young People)
- NA
- NA (Beginners)
- NA (Young People)
- SMART Recovery
- Celebrate Recovery
- PAL (Parents of Addicted Loved Ones)
- GRASP (Grief Recovery After a Substance Passing)
- All Recovery
- DTR (Double Trouble in Recovery)
- MA (Marijuana Anonymous)
- Al-Anon
- Nar-Anon
- Collegiate Recovery Community Support
Training Type*
- Addiction Training Center (Certified Event Interventionist)
- CCAR Training (Comprehensive Capital Analysis and Review)
- CRPS-P Work Study,
Event Type*
- Grand Opening
Center Resource*
- Game Room
- Recovery Lounge
- Coffee Lounge
- Meeting Room 1
- Meeting Room 2
- Desert Room (Peer Room 1)
- Coastal Room (Peer Room 2)
- Jungle Room (Peer Room 3)
- Board Room
- Computer Workstation
Please briefly describe what you would like to discuss*
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Request Contact
Please provide the following information and we will get back to you shortly.
I am:*
- A current Member
- Interested in becoming a Member
Please Enter Your Participant Short Code:*
Your participant short code is your first initial, last initial, birth month, day and year in the following format: FL01311990 Where First Last's birth date is 01/31/1990.
Name*
First Last
Please contact me via:*
- Phone
- Email
- Phone or Email
Phone # for Contact*
Email for Contact*
Please briefly describe what you would like to us to contact you about*
Recovery Support Services Intake Packet
The survey will take approximately 22 minutes to complete. Thank you for choosing to seek Recovery Support Services with us. Fill out the below form to the best of your ability in order to best help us to guide your next steps. A Certified Recovery Peer Specialist looks forward to working alongside your recovery journey.
Name*
First Last
Email

If you don't have an email address, please input "no@email.com".
Phone*
Please enter (000)-000-0000 if you do not have a phone number
Address*
Street Address Address Line 2 City State ZIP Code
How did you hear about us?*
- Friend/Family
- Treatment Provider
- Probation officer
- Emergency Department
Reason for Referral
- Select All
- Housing
- Employment
- Education
- Connection to treatment
- Connection to recovery community
- Recovery support
- Probation
- Overdose
- Co-occurring
- Multiple treatment episodes
Demographic Information
Date of Birth*
MM slash DD slash YYYY
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:*
Gender (select all that apply)*
- Male
- Female
- Nonbinary
- Transgender
- Prefer to Self-describe
Gender:*
Orientation/Identity*
- Straight
- Lesbian
- Gay
- Bisexual
- Queer
- Prefer to Self Describe
Other Orientation/Identity*
Pronouns*
Intake Information
Date of Last Use
MM slash DD slash YYYY

Open and honest is the best policy here.
Custody of Children?
- Yes
- No
Are you on probation/parole?
- Yes
- No
Veteran Status
- Veteran
- Not a Veteran
How old were you when you first started using?
Please enter a number from 0 to 100.
In the past 30 days, I have used...*
- Alcohol
- Benzodiazepines (Xanax)
- Cocaine/Crack
- Fentanyl
- Hallucinogens (Mushrooms. LSD, PCP)
- Heroin
- Marijuana
- Meth
- Methadone (WITHOUT prescription)
- Tobacco
- None
- Other
Other Substances used in past 30 days...*
Challenging Substances*
- Alcohol
- Benzodiazepines (Xanax)
- Cocaine/Crack
- Fentanyl
- Hallucinogens (Mushrooms, LSD, PCP)
- Heroin
- Marijuana
- Meth
- Methadone (WITHOUT prescription)
- Opioids (WITHOUT prescription)
- Tobacco
- None
- Other
Other Challenging Substances*
Have you been to treatment?*
- Yes
- No
Have you been to treatment in the last 30 days?*
- Yes
- No
How many times have you been administered Narcan?*
Please enter a number from 0 to 100.
How many times have you been to emergency room?*
- Never
- 1 time
- 2 times
- 3-5 times
- More than 5 times
Total Number of Criminal Charges*
Please enter a number from 0 to 100.
Have you been arrested in the last 30 days?*
- Yes
- No
Do you have a stable place to live?*
- Yes
- No
- Don't Know
- Refused
Housing Status*
- Own/rent house
- Own/rent apartment
- Recovery housing
- Hotel/motel
- Homeless
- Shelter
- Other
Other Housing Status*
Size of your household?*
Please enter a number from 0 to 100.
Who do you live with?*
- Spouse
- Parent(s)
- Family
- Girlfriend
- Boyfriend
- Friend
- None
- Other
Other people you live with*
Highest Level of Education*
- Elementary/Grade School
- High School/GED
- Technical School
- Bachelors
- Masters / Phd
- None
Employment Status?*
- Not Employed - Not Looking for Work
- Not Employed - Looking for Work
- Employed Part Time
- Employed Full Time
- Other
Other Employment Status*
Are you satisfied with your education/employment?*
- Yes
- No
Income Sources*
- From Employment Only
- Employment and Other Sources
- Not Applicable
- Refuse to Answer
- Other
Other Income Source*
Other Income Sources*
- TANF
- Supplemental Security Income (SSI)
- Social Security Disability Income (SSDI)
- VA Service Connected Disability Compensation
- VA Non Service Connected Disability Pension
- Private Disability Insurance
- Worker's Compensation
- Retirement Income from Social Security
- Pension
- Child Support
- Alimony or other Spousal Support
- Unemployment Insurance
- EITC
- Not Applicable
- Refuse to Answer
Non-Cash Benefits*
- SNAP
- WIC
- LIHEAP
- Housing Choice Voucher
- Public Housing
- Permanent SUpportive Housing
- HUD-VASH
- Childcare Voucher
- Not Applicable
- Refuse to Answer
- Other
Other Non-Cash Benefits*
What is your annual income range?*
- No Income
- Under $10,000
- $10,001-$20,000
- $20,001-$30,000
- $30,001-$40,000
- $40,001-$50,000
- $50,001-$60,000
- $60,001-$70,000
- $70,001-$80,000
- $80,001-$100,000
- $100,000 or above
Physical Health*
- Poor
- Fair
- Good
- Excellent
History of Seizures?*
- Yes
- No
Access to transportation?*
- Yes
- No
Do you have insurance? If so what kind?*
- 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

Recovery Capital Data
Rate the following questions on a scale of 1 to 5: 1-Strongly Disagree, 2-Disagree, 3-Sometimes, 4-Agree, and 5-Strongly Agree
I have the financial resources to provide for myself and my family.*
I have personal transportation or access to public transportation.*
I live in a home and neighborhood that is safe and secure*
I live in an environment free from alcohol and other drugs.*
I have an intimate partner supportive of my Recovery process.*
I have family members who are supportive of my Recovery process.*
I have friends who are supportive of my Recovery process.*
I have people close to me (intimate partner, family members, or friends) who are also in Recovery.*
I have a stable job that I enjoy and that provides for my basic necessities.*
I have an education or work environment that is conducive to my long-term recovery.*
I continue to participate in a continuing care program of an addiction treatment program, (e.g., groups, alumni association meetings, etc.).*
I have a professional assistance program that is monitoring and supporting my Recovery process.*
I have a primary care physician who attends to my health problems.*
I am now in reasonably good health.*
I have an active plan to manage any lingering or potential health problems.*
I am on prescribed medication that minimizes my cravings for alcohol and other drugs.*
I have insurance that will allow me to receive help for major health problems.*
I have access to regular, nutritious meals.*
I have clothes that are comfortable, clean and conducive to my Recovery activities.*
I have access to Recovery support groups in my local community.*
I have established close affiliation with a local Recovery support group.*
I have a sponsor or a special mentor related to my Recovery.*
I have access to online Recovery support groups.*
I have completed or am complying with all legal requirements related to my past.*
There are other people who rely on me to support their own recoveries.*
My immediate physical environment contains literature, tokens, posters or other symbols of my commitment to Recovery.*
I have recovery rituals that are now part of my daily life.*
I had a profound experience that marked the beginning or deepening of my commitment to Recovery.*
I now have goals and great hopes for my future.*
I have problem solving skills and resources that I lacked during my years of active addiction.*
I feel like I have meaningful, positive participation in my family and community.*
Today I have a clear sense of who I am.*
I know that my life has a purpose.*
Service to others is now an important part of my life.*
My personal values and sense of right and wrong have become clearer and stronger in recent years.*

Recovery Management Planning
Please select 1 Recovery Domains you would like to evaluate, discuss and work on in your recovery.
Recovery Domain*
What is your assessment of the Recovery Domain selected?*
- Very Satisfied
- Satisfied
- Neutral
- Dissatisfied
- Very Dissatisfied
Explain rating for the Recovery Domain selected:*
Contact Preferences
I am interested in:*
- Recovery Coaching
- Telephonic Recovery Supports
- Both Telephonic and In-person Recovery Services
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
Best Days to Call:
- Select All
- Mondays
- Tuesdays
- Wednesdays
- Thursdays
- Fridays
- Saturdays
- Sundays
Best Time to Call
- Morning
- Afternoon
- Evening
- Anytime
Additional Consents
Release of Information

I authorize Recovery Connections of Central Florida to release/obtain the below information. I understand that I have the right to see this information at any time. I understand that I can revoke this consent in writing to both the person giving and the person receiving the information. Any information already released may be used as stated on this form. I understand the requested or provided information is needed to assist in my recovery management plan. This consent is valid only until 6 months from date of this intake. This consent is not automatically renewable. It expires at the end of the period specified unless revoked in writing sooner. By selecting below, I affirm that I have read this release, or it has been read to me, and I understand its consent.
Release of Information selections*
- Recovery Management Plan Update
- Active/Inactive Status
- Discharge Summary
- Contact Information
- Refuse
- Other
Other Release of Information*
I authorize release of the above information to...*
Put the Name, Relation, Contact Info of said person(s) you'd like to authorize the above information to be released to. (If you selected Refuse - Put N/A)
Recovery Connections of Central Florida provides Recovery Support Services on a sliding scale

If your income is at or below 150% of the Federal Poverty Guidelines, then there is no charge for your services. If your income is above this threshold, you will be charged a nominal fee of $3.00 per session. If you are unable to make this payment for any reason, we are happy to set up a payment plan for you.
If you select Refuse we will not deny you services.*
- I acknowledge that I have provided my income information to the best of my ability, and have seen and understand my rights regarding this policy
- Refused
Participant Monthly Household Income:*
Family Size*
Copayment Due*
Participant Signature*
Peer Support Specialist Name
Peer Support Specialist Signature
Signature Date*
MM slash DD slash YYYY