Survey | 12-2-1 Roundtables

12-2-1 Roundtables follow-up Survey

Thanks for taking a few minutes to let us know how things are going for you. We appreciate it!

First name

Last name

Address

Country/Region

Address

City

Zip / Postal code

Email

Phone

Employment Status:

Substance Use Status:

Have you used alcohol or other drugs in the last 30 days?

Yes

No

Have you used alcohol or other drugs in the last 6 months?

Yes

No

Have you used alcohol or other drugs in the last 12 months?

Yes

No

What is your current clean date?

Describe your substance use since being in the Roundtables

I have used regularly

I have used 10 times or less

I have used on one occasion only

I have not used and continue to maintain sobriety

Check this box if you are on MAT but are tapering down.

Support Group Status:

Please check all that apply

I attend 12-step meetings regularly (1/wk or more)

I attend 12-Step meetings occasionally (less than 1/wk)

I don't attend 12-step meetings

I attend a faith-based group regularly

I attend a faith-based group occasionally

I do not attend a faith-based group

I participate in S.M.A.R.T. Recovery

Other

12-step Recovery Support Status:

Legal / Case Status:

I have successfully completed Drug Court, Probation, Parole, or other court-ordered community-based alternative and have had no new arrests

I am still attending any one of the above for a sentence given to me before the start of the Roundtables, and have had no new arrests

I have a new criminal case since I left the Roundtables

Other

Family / Reunification Status:

Please check all that apply

I have been successfully reunified with my children

I am still in my improvement period

I am getting more time with my children

I am getting unsupervised visits with my children

I still have an open CPS case

My CPS case is closed

No significant change in my case

I do not have a CPS case

Other

Please describe any additional significant changes in your life since you were in the Roundtables that you would like us to know about.

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12-2-1 Roundtables

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12-2-1 Roundtables follow-up Survey