Survey - Fresh Start Recovery Referral Form - Indiana

Veterans & their Families: Overview; Housing; Employment & Training; Supportive Services

Fresh Start Recovery Referral Form - Indiana

Patient/Client Information

Name:

First Required	Middle Required	Last Required

Email: Required

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number: Required

*2.

Question - Required - Opioid substance use (for example, may include codeine, morphine, or fentanyl, or percoset):

*3.

Question - Required - Has an open case with Department of Child Services: If yes, please include Family Case Manager's contact info at the bottom of this form.

*4.

Question - Required - Currently has children:

Question - Not Required - If yes, how many are under five years old?

Question - Not Required - If yes, would children (up to 2 children, under the age of 5) live with mother at the treatment facility?

*7.

Question - Required - Currently pregnant:

Question - Not Required - If yes, how many weeks gestation?

Question - Not Required - If yes, is prenatal care being received?

10.

Question - Not Required - Currently homeless?

*11.

Question - Required - Willing to participate in Family Coach aftercare services for up to one year post-delivery (Family Coach meets with family to work on employment, housing, education, parenting skills, and addiction treatment support to reduce risks associated with relapse):

*12.

Question - Required - Referral source information
Please make 1 selection from the choices below.

	Self-referral
	Practice/organization referral

13.

Question - Not Required - Referral source name:

14.

Practice/organization information

Name:

First Required	Last Required

Email:

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

Phone Number:

15.

Question - Not Required - Specific concerns/requests/recommendations:

(Maximum response 255 chars, approx. 5 rows of text)

16.

Question - Not Required - (If applicable) DCS Family Case Manager name, phone number, and email address:

(Maximum response 255 chars, approx. 5 rows of text)

*17.

Question - Required - Preferred Recovery Center Location:

Indianapolis

Columbus, IN

Evansville

Winchester

No Preference

Ohio Office

Volunteers of America Ohio & Indiana

1776 East Broad Street, Columbus, OH 43203

614-253-6100

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