Today's Date
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Current use of substance of choice? *
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How many times have you been arrested since entering treatment? *
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How many times have you been admitted to a emergency department or medical facility due to or partially due to drug or alcohol use since entering treatment? *
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How many times have you been admitted to a mental health facility(inpatient or outpatient) due to or partially due to drug or alcohol use since entering treatment? *
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Are you employed or enrolled in a school? *
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How many times have you missed work or school due to drinking or drug use since entering treatment? *
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Have you gotten into financial difficulty due to your drinking or drug use since entering treatment? *
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Do you currently have health insurance? *
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Are you currently or are you planning on using Medication Assisted Treatment (Antabuse/Naltrexone/Suboxone/Vivitrol/Naloxone/Buprenorphine etc)to assist in your recovery? *
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Are you currently seeing a therapist/counselor/coach/prescriber to maintain your recovery? *
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Are you currently engaged in some form of exercise to assist in your recovery? *
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Are you currently involved with any religious and/or spiritual based activities to assist in your recovery? *
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How many recovery support groups(NA/AA, Smart Recovery) do you attend per week? *
Have you been able to maintain continuous abstinence from all substances and alcohol?
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12 Month Treatment Survey

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