Evaluation at the Recovery Centers Last Updated July 10, 2013
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1 Evaluation at the Recovery Centers Last Updated July 10, 2013 How do you identify: 1. I consider myself (please check all that apply): a person with a history of alcohol or drug abuse/addiction a person with a history of problem or compulsive gambling a person with a history of mental illness a family member of someone with a history of substance abuse, gambling, or mental illness 2a. Do you consider yourself to be transgender? Refused 2b. If you answered to Q. 2a, please specify: Male to Female Female to Male Other, specify 3. Do you consider yourself to be: Heterosexual /Straight Gay/Lesbian Bisexual Other, specify Refused Economic & Housing Stability: One sign people are moving toward a more grounded and stable place in their recovery relates to whether they have a way to support themselves financially and a safe place to live. This can look different for everyone depending on where they are in their recovery and what their personal goals are. Getting information about how you support yourself financially and your current housing status can help centers better understand and develop information, activities and supports that meet needs of the community. 4. What does your current employment or educational situation look like? (Please check all that apply to you.) Working full-time Working part-time Looking for work Unemployed Enrolled in GED program Enrolled in a skills or certificate training program Taking classes in a part-time or full-time college program Other:
2 5. Are you accessing any of the following supports? (Please check all that apply) Unemployment Benefits Welfare / cash assistance Food stamps WIC Women, Infants, and Children TAFDC Temporary Aid to Families with Dependent Children Fuel Assistance Programs (to help pay utility bills) Retirement/Pension Child Support Alimony Social Security Insurance / Social Security Disability Insurance Housing Assistance (for example: Section 8, rental assistance, housing voucher programs, etc.) Veteran s Benefits Worker s Compensation Food pantry Other (for example clothing pantry): 6. Do you have health insurance? (For example self-pay, through your work, or public options like MassHealth) 7. Which category best describes your current living situation? (Please check all that apply to you) Public Housing Living with Family/Friends Sober Housing Group Home Residential Treatment/Halfway House Renting: Room/Apartment Own a condo/house Short or Long-Term Housing Program Veteran s Shelter Homeless Shelter Safe House for Domestic Violence Other: 8. Do you consider your current living situation to be safe? 9. Do you consider your current living situation to be supportive of your recovery?
3 Criminal Justice Involvement: For many of us when we were using alcohol and/or drugs our actions and choices often led to criminal behavior and our involvement in the legal system. Part of recovery is trying to take responsibility for our past choices and change old behaviors, which includes learning to make safer and healthier choices for ourselves, others around us, and our local community. Knowing about this area helps the center plan for things like education about sealing a CORI, having a CORI and looking for jobs, looking for housing with a CORI, etc. 10. Have you ever been arrested? (If you checked no skip to question 12 below) 11. How long has it been since you were last arrested: 12. Have you ever been in jail/prison (for example a House of Correction, State Prison, etc.)? (If you checked no skip to question 12 below) 13. How long since you were released? Use, Abstinence & Recovery Status: For many people learning to live a life free of alcohol, drugs and tobacco, or free from gambling if you are recovering from problem gambling, is a central to their recovery. Having a desire to use alcohol or drugs less, or gamble less, can be a sign someone is making progress toward a healthier lifestyle. The questions below are designed to provide information on where people are at in their recovery process. 14. Do you have a history of substance abuse/addiction? (If you checked no please skip to question 16 below.) 15. Which best describes your current situation: I am using and do not currently plan to stop or cut down on my alcohol or drug use I am using but I m thinking about cutting down or stopping my alcohol or drug use I am using less frequently or less in amount when I do use alcohol or drugs I am using but I m seeking help for my problem with alcohol or drugs I am not using and I m in recovery from my alcohol or drug use
4 16. How long has it been since you last used alcohol or drugs? Earlier today 1 to 30 days. 31 to 60 days.. 61 to 90 days. 91 days to 6 months. 7 months to 1 year. 1 to 2 years. 3 to 5 years. more than 5 years. 17. When was the last time you were treated at an alcohol or drug related detox program? I ve never been to a detox 18. Do you have a history of problem gambling? (If you checked no please skip to question 19 below) 19. Which best describes your current situation: I am gambling and do not plan to stop or cut down my gambling I am gambling but I m thinking about cutting down or stopping my gambling I am gambling less frequently or less in amount when I do gamble I am gambling but I m seeking help for my problem I am not gambling and I m in recovery from my gambling problem 20. How long has it been since you last gambled? Earlier today 1 to 30 days. 31 to 60 days.. 61 to 90 days. 91 days to 6 months. 7 months to 1 year. 1 to 2 years. 3 to 5 years. more than 5 years 21. Do you currently use tobacco? (If you checked no please skip to question 23 below)
5 22. Which best describes your current situation? I am using tobacco and do not plan to stop or cut down I am using tobacco, but I m thinking about cutting down or stopping I am using less tobacco (smoking less, using dip less, etc.) I am using tobacco, but I m trying to stop 23. When was the last time you were treated at an emergency room? I ve never been treated at an emergency room 24. When was the last time you were treated at an inpatient psychiatric hospital? I ve never been treated at an inpatient psychiatric hospital Social Connectedness: Social connectedness means creating satisfying and trusting relationships in recovery and feeling part of a community that supports your recovery and whose recovery you can also support (includes: friends, family, 12 step communities, faith-based communities, etc.). Since most people are not able to recover in isolation, learning to develop trusting relationships with others is a sign of moving toward a lifestyle that is supportive of individual recovery. 25. Do you feel more connected to the recovery community as a result of participating in the center? 26. Are you able to develop safe relationships that support your recovery at the center? 27. Since coming to the center, I feel more connected with: (Please check all that apply) Members or Staff at the Recovery Support Center Other friends/supports outside the center Family members (however you define family) Members of 12 Step Fellowship Members of other Support Groups Members of Faith Based Communities Members of Social/Recreational/Civic groups or organization in the community
6 Other, please describe below: ne of the above Meaningful Things to Do: Having a sense of purpose, either through giving back to others/the community, or through participation in activities that are enriching spiritually, emotionally, recreationally or educationally is an important part of feeling centered in one s recovery. These questions ask how much the center helps with this in your life. 28. Do you find opportunities at the center to share your lived-experience to support others in recovery (giving back, mentoring, etc )? 29. Do you volunteer at the center? 30. Do you find opportunities at the center to develop new skills or further develop existing skills? 31. Do you find opportunities at the center to share your skills/talents with others or the community? 32. Do you attend meetings or groups at the center that support your recovery? 33. Does the center present you opportunities to get involved in fun activities that are alcohol and drug free?
7 Center Participation: Below are two questions about how often you attend and how long you have been involved in the center. We are asking these questions because we'd like to see what the relationship is between someone's recovery status and quality of life and his/her frequency of attendance or length of time at the center. 34. How often do you come to the center? Daily 3 to 5 times a week 1 or 2 times a week 2 to 3 times a month once a month not very often, just when I feel like dropping in 35. How long have you been coming to the center? Less than one month 1 to 3 months 4 months to 6 months 7 months to 1 year 1 to 2 years More than two years 36. Is there anything else you would like us to know about your experience at the center, for example resources, activities or supports you wish were offered at this center? On behalf of the Massachusetts Department of Public Health, Bureau of Substance Abuse Services and the Recovery Support Centers thank you for taking the time to answer the above questions and helping us to better understand the effectiveness of the centers.
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