Exit Interview. Please place an X in the appropriate box of why you are leaving the program. Entry Process
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1 Exit Interview Please place an X in the appropriate box of why you are leaving the program Graduating the Program: Terminated: Opting Out: Entry Process 1. How did you first learn that this program was an option for you? Attorney Friend In custody Probation Officer Court Other: Family Peer 2. Did you start this program in custody or were you out of custody and had pending your charges? In Detention/Jail when I entered Out of custody (Detention/Jail) when I entered In residential treatment 3. Why did you originally choose to come into this program? To get out of jail Treatment available Less incarceration time Support/structure Financial benefit Keep license Resources available No conviction Other
2 Court Aspect of This Program 4. During orientation, how well was all the necessary information about program rules, regulations, and expectations explained to you? Not at all Fair Average/Decent Good Explained well 5. What aspects of the court supervision do you feel is helpful to you (Please check ALL that you feel motivates you)? Positive interaction with the Judge Sobriety coins Phasing up ceremonies Rewards/Incentives for doing good reaching goals Community Service/Work Crew Extra recovery support groups Home visits Writing assignments/essays Increasing court reporting Detention/Jail or threat of Detention/Jail 6. What aspects of the court supervision do you feel is LESS helpful to you in motivating you (Please check ALL that apply)? Positive interaction with the Judge Sobriety coins Phasing up ceremonies Rewards/Incentives for doing good reaching goals Community Service/Work Crew Extra recovery support groups Home visits Writing assignments/essays Increasing court reporting Detention/Jail or threat of Detention/Jail
3 Treatment Aspect of This Program 7. What aspect of treatment do you feel really HELPED you? Please list/explain your answer below. 8. What aspect of treatment do you feel was LEAST helpful to you? Please list/explain your answer below. 9. While you have been in this program, have you been referred to Inpatient treatment? No I wasn t referred but I went to inpatient on my own Yes, and completed inpatient Yes, but never went to inpatient Yes, and went to inpatient but did not complete Yes, and went to inpatient twice List Inpatient Treatment Center Name and length of stay (# of months) 10. Prior to this program, have you been under the supervision of any of the following? Probation/Parole Inpatient treatment Social Services/CPS Out-patient treatment Other treatment court program
4 Personal Experience in This Program 11. Do you feel comfortable enough to be able to talk to at least one person on the treatment court team? Please select each member on the team that you feel comfortable sharing information. Treatment Counselor/Case Manager Treatment Court Coordinator Law Enforcement Probation Officer Judge Child Worker / CASA Defense Attorney Prosecuting Attorney Other Counselor (MH, DV, etc) Educator I don t feel comfortable sharing with anyone at this time Other (please specify) 12. Did you receive sanction(s) while in this program? Please check ALL that apply to you. Community Service Work Crew Extra meetings Jail Detention Written assignment Curfew EHM YES # of hrs. NO Other (please specify) 13. Did you receive rewards while in this program? YES NO If YES, what did you receive?
5 14. What difficulties/barriers have you experienced while in this program? Transportation Childcare Obtaining driver s license Finances Education Employment Mental Health Counseling Lack of family/peer support Making appointments Obtaining State ID Medications Sober housing Relating to/trust of staff Medical/Dental issues Other counseling/classes Changing attitude/beliefs Recovery environment Other (please specify) 15. Did you receive any extra services or help to overcome some of these barriers while in this program? YES NO If YES, what did you receive? 16. Which community support groups do you attend? Alcoholics Anonymous Narcotics Anonymous Church / Youth Group Bible Study SMART Recovery Domestic Violence support Organized sober/recovery activities (bowling, softball, retreats, campouts, etc) Other (please specify)
6 17. In your opinion, what are YOU most proud of in your life today? 18. What comments and/or changes would you like us to know about or think about for the program? 19. If you are opting out, why are you leaving the program?
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