Recovery Intake Form | Her Resilient Recovery

RECOVERY COACH INTAKE FORM

This form is completely confidential, but an important building block in our relationship. We are trying to get a clear picture of where you are now, and where you’d like to be. Please be as honest and specific as you can. We need some biographical information (name, age, etc) as well. If you have any questions about this, please contact your recovery coach by email or phone.

Date *

Select *

Basic Information

Legal Name *

First Name Preferred

Gender *MaleFemaleOther-Identified

Specify (optional)

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address *

What prompted you to reach out for help at this time? *

What was the first substance you consumed, and when? *

When did the substance use become a problem? *

What substances are currently a concern? *

Can you give a brief description of your substance use as it progressed from start to today? *

Recovery History

What is your previous treatment or recovery history and dates (if applicable)? *

What recovery approaches have worked? *

What has not worked?

Are you looking to moderate your drug use or quit completely? *ModerateQuit Completely

Goals

1. What are some of the ways you'd like to improve your life from our work together? *

Health and Well Being Information

Having a general understanding of current health issues and past health history and significant life events can help us know how best to support you in participating in the coaching process.

Please list any previous significant injuries, physical and behavioural health conditions, and overnight hospitalizations for medical, surgical or psychological conditions (include year, where applicable): *

Have you experienced any major adverse, traumatic or extremely stressful life events? *YesNo

If so, please briefly describe the event(s), including the date(s) of the experience(s)?

Are you aware of any current symptoms or behaviours as a result of the experience(s)? *YesNo

Do you sometimes feel overwhelmed by the experience(s)?YesNo

How have you supported yourself in healing (i.e., therapy, counselling, education, medication or other means)? *

Do you feel as if you have worked through the experience(s) in a way that has made it/them manageable in your life?YesNo

Mental Health Assessment

Are you currently engaged with counselling, therapy, psychotherapy, or psychiatric care? *YesNo

In the Past? *YesNo

If current, the names of your counsellor, therapist or psychiatrist?

During the last month have you (check yes or no):

A. Sought psychiatric help?B. Had thoughts of death or dying?C. Had urges to smash or break things?D. Had spells of terror or panic?

When you are feeling stressed, or overwhelmed what do you normally do? *

What gives you the most pleasure in your life? *

What are you most worried about? *

Is there anything else you would like to share, or think important that we know about so we can best support you in participating in this class? *