Indy Support Navigator

Thrive Recovery Intake

Intake Form

Coach Assignment
Date
Treatment Center
Discharge Date from Treatment
First Name
Last Name

Prior THRIVE Involvement

Have you ever signed up for Thrive?
Have you worked with an IRACS Thrive coach from Clark County Jail?

Client Demographics

Birthday
Social Security Number
Gender
Are you pregnant?
Race
Are you Hispanic or Latino?
Your Phone Number
Address
City
State
Zip Code
Which county will you be living in?

Alternate Contact

If you do not have an active phone number, do you have a friend or family member that we could contact to reach out to you?

Alternate Contact
Their Name
Relationship
Phone Number

Legal / Court / Child Welfare Information

Do any of the following apply to you? Check all that apply.
Probation or Parole: Where are you reporting to?
Involvement with a Problem Solving Court: Which one?

Recovery, Substance Use, and Mental Health Information

Do you have a recovery or sobriety date?
What was your substance of choice?
What is your recovery pathway?
Are you on an MAT / MAR program?
How many times have you been to treatment for substance use?
How many times have you been to inpatient treatment for mental health only?
Highest Level of Education?
Marital Status?
How many children do you have?
Are you a Veteran?
Do you have state or private insurance?
Have you been diagnosed with any mental illness or personally identify as having mental illness? (Depression, Anxiety, PTSD, Bipolar, Schizophrenia, etc.)

Recovery Goals / Areas of Support

What are some goals you would like to work on in your recovery? Below are some common things people may need or be interested in speaking with a coach about. Please check those that best describe your needs. If there is something not listed, please write more about it in "Other."

Other goals / areas of support

Consent for the Release of Information under 42 C.F.R. Part 2

Confidentiality of Substance Use Disorder Patient Records

I, ____________________________________, hereby authorize THRIVE (provider) to disclose information regarding my mental health and substance use disorder history to Indiana Division of Mental Health and Addiction (DMHA) for the purposes of de-identified data collection and payment administration regarding services paid through DMHA Electronic Billing System (DEBS).
I understand that my substance use disorder patient records are protected under federal regulations 42 C.F.R. Part 2 - Confidentiality of Substance Use Disorder Patient Records and cannot be disclosed without my written consent. I do not need to sign this form to obtain treatment. I may revoke this consent in writing at any time. I understand that the revocation will not be effective retroactively for information disclosures that have already occurred. If not previously revoked, this consent will terminate upon termination of mental health and addiction services with the provider listed above.

Patient/Legal Representative Signature
Clear
Dated

Notice of Federal Requirements Regarding the Confidentiality of Substance Use Disorder Patient Information

The confidentiality of substance use disorder patient records maintained by this program is protected by federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug user unless:

The patient consents in writing; or

The disclosure is allowed by a court order accompanied by a subpoena; or

The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation; or

The patient commits or threatens to commit a crime either at the program or against any person who works for the program,

Violation of federal law and regulations by a program is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs. Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

The releases of information will remain active and valid until termination of mental health and addiction services with the provider listed above OR until a specific date, event, or condition as listed on the form.

(See 42 U.S.C. § 290dd-2 for federal law and 42 C.F.R. Part 2 for federal regulations governing Confidentiality of Substance Use Disorder Patient Records.)

Authorization to Disclose Form

Authorization for Disclosure of Confidential Information

I, Client Name

Participant Income Eligibility Certification Form

(Income at or below 200% of Federal Poverty Level)