2021 Adult Follow-Up Survey

BACKGROUND INFORMATION

This questionnaire asks questions about your background, drug and/or alcohol use, medical status, employment, legal status and family relationships. It should only take about 10 minutes. Your answers are completely CONFIDENTIAL and will help us continue to improve our services and provide our patients with the best care possible. Please answer each question as accurately as you can. Fill in the blanks or place a check mark in the appropriate box. Thank you.

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* 1. Todays Date

Date:

Date

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* 2. Name (please do not enter in your last name only last initial)

First name

Last initial, only

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* 3. Date of Birth

Date of Birth

Date

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* 4. Person completing this survey:

Self (patient)

Family Member

Other

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* 5. Which program did you participate in?

Rimrock

White Birch North

White Birch South

Ada's House

Cedar Way

Michel's House

Willow Way

Rimrock Day Treatment

Rimrock IOP (Intensive Outpatient)

Silver Leaf/Treatment Court IOP (Intensive Outpatient)

Silver Leaf/Treatment Court Day Treatment

True North

Other (please specify)

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* 6. Which Treatment Court did you participate in?

Impaired Driver's Court (STEER) (Judge Knisley)

Adult Municipal Drug Court (Judge Kolar)

Adult Municipal DUI Court (Judge Kolar)

CAMO (Judge Knisley)

Adult Co-Occuring Court (Judge Kolar)

Family Recovery Court (Judge Todd)

Does not apply

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* 7. When were you discharged from treatment at Rimrock?

Approximately 6 months ago

Approximately 12 months ago