peer and pcoms* services forms -...

Brauchtworks Consulting:

Applying Science to Practice

Peer and PCOMS* Services Forms

George S. Braucht, LPC

CARES Co-founder

Brauchtworks Consulting

Email: [email protected]

Phone: 404-310-3941

Website: www.brauchtworks.com

*The Partners for Change

Outcome Management System (PCOMS) is in SAMHSA’s

National Registry of Evidence-based Program and Practices:

http://legacy.nreppadmin.net/ViewIntervention.aspx?id=250

Peer and PCOMS Services Forms www.brauchtworks.com Page 1 of 28

Peer and PCOMS Services Forms: Table of Contents

* = Download from www.heartandsoulofchange.com All other forms are available at www.brauchtworks.com Page

1. Forms Downloading Instructions ..................................................................... 3

2. CARES Core Competencies Self-assessment and Development Plan ................ 4

3. *PCOMS: (Peer) Relationship Rating Scale (RRS) ........................................... 7

4. *PCOMS: Session Rating Scale (SRS; Adult)...................................................... 8

5. Individual PCOMS Spreadsheet Sample ........................................................... 9

6. Program PCOMS Spreadsheet Sample ............................................................. 11

7. Recovery Action and Progress (RAP) Group Facilitator Guidelines ............ 13

8. Recovery Action and Progress (RAP) Group Preparation Checklist ............. 14

9. Recovery Capital Scale and Plan ................................................................... 15

10. Resident Overnight Activities for Recovery (ROAR) Request ........................ 20

11. Resident Personal Recovery Information and Discharge (Transfer)

Expectations (PRIDE) Report ..................................................................... 21

12. Understanding of Alcoholism Scale Interpretation Handout .................... 22

13. Page 1.1: Recovery Check-in Overview ............................................................ 23

14. Page 1.2: Recovery Check-in Form .................................................................. 24

15. .1: Self-Completed Overview of Recovery Experience (SCORE) Board

- WHAM ......................................................................................................... 25

16. Page 2.2: Recovery Action and Progress (RAP) Group Handout ................. 26

17. *Page 3.1: PCOMS - Outcome Rating Scale (ORS; Adult) ............................. 27

18. *Page 3.2: PCOMS - Group Session Rating Scale (GSRS) ................................ 28

Upon requesting permission from George Braucht ([email protected]),

organizations may remove from associated forms Brauchtworks Consulting and

its logo although an acknowledgement of the source would be appreciated.

Brauchtworks Consulting Applying Science to Practice www.brauchtworks.com Certified PCOMS & Recovery Coach Trainer

Peer and PCOMS Services Forms Download Instructions 160712

George S. Braucht, LPC; Email: [email protected]; Phone: (404) 310-3941

The Partners for Change Outcome Management System (PCOMS) forms are FREE for individual users - a group license is required for agency or organization use at a reasonable, one-time cost – however, the forms are copyrighted and require completing an online, simple licensing agreement. A PCOMS intervention summary is available at SAMHSA’s National Registry of Evidence-based Programs and Practices: http://legacy.nreppadmin.net/ViewIntervention.aspx?id=250. Adult (18+), adolescent (17-13), child (12-6), young child (5 and below) versions are available in 22 languages (so far) along with and oral or telephone scripts in English. Therapist/counselor: Outcome Rating Scale (ORS) = begin individual interactions and groups Session Rating Scale (SRS) = use toward the end individual interactions Group Session Rating Scale (GSRS) = use toward the end of groups Peer service provider: Outcome Rating Scale (ORS) = begin individual interactions and groups Relationship Rating Scale (RRS) = use toward the end of interactions Group Session Rating Scale (GSRS) = use toward the end of groups To access the PCOMS scales:

1. Go to www.heartandsoulofchange.com 2. At the top of the page click on “Measures” 3. Review the licensing agreement 4. Click on “click here” and register your email address 5. Notice the different links for professional and peer versions, the Group Session Rating

Scale, and oral scripts Below is a partial list of additional forms for professionals and peers available at

http://brauchtworks.com/change_agent_toolkit

Acute Care Treatment and Recovery-oriented Systems of Care Comparison Addiction Treatment and Recovery Services Practices Overview Individual Constructive Assessment of this Recovery Environment (ICARE): Outpatient and

Residential Programs Knowing a Recovery Culture When You See One Monthly Recovery Report: Outpatient and Residential versions completed by the client PCOMS Monthly Report in Excel Recovery Capital Scale and Plan Recovery Check-Ins Overview Recovery Check-Ins Telephone Practice Guides: Initial and Ongoing Recovery Coach Monthly Report Sample Recovery Coach Supervisor Monthly Report Sample Recovery Groups Handout Relationship Enhancement (OARS) Skills Overview Self-Completed Overview of Recovery Experience (SCORE) Board

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Brauchtworks Consulting Applying Science to Practice www.brauchtworks.com Certified PCOMS & Recovery Coach Training

CARES Core Competencies Self-Assessment & Development Plan 160712

Name: _________________________ Today’s Date: _______ CARES Academy Date _______ Store this assessment and plan in your CARES Manual for future reference Assessment # ____ Instructions: Without looking at your previous assessment, mark () each dotted line under each item in sections A, B, and C. After marking all items, align the 0 on a centimeter ruler with the beginning of each line and write the number (1-10) that is closest to your mark in the blank at the end of the line. Calculate the average for each section then enter below.

CARES Core Competencies Self-Assessment Score:

RA ______+ RC ______ + RG ______= _________/3 = ________ = Current Competency 0 = Novice = Improvement needed; 10 = Expert = Improvement not needed

During this assessment period I recorded, self-assessed and/or received performance support on: Check all that apply.

Recovery advocacy: My elevator speech Recovery advocacy: SOAR presentation

Recovery check-ins Recovery Groups PCOMS Skills Competency Assessment

Other: _____________________________________________________________________

My CARES Core Competencies Development Plan: Review & revise every 3-6 months!

Strengths: Enter highest rated items’ #s (1-0) _____________________________________ Review your last self-assessment and build on the progress made with previous goals, tasks and resources and/or add new areas for improvement from the lowest rated #1-#20 items.

Improvement areas I will work on in the next 6 months: 1. Goal: _____________________________________________________________________ _____________________________________________________________________

Tasks & Needed Resources: ________________________________________________ _____________________________________________________________________

2. Goal: _____________________________________________________________________ _____________________________________________________________________

Tasks & Needed Resources: ________________________________________________ _____________________________________________________________________

3. Goal: _____________________________________________________________________ _____________________________________________________________________ Tasks & Needed Resources: ________________________________________________

__________________________________________________________________

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CARES Core Competencies Self-Assessment & Development Plan (cont.)

Novice = Improvement needed -------- Expert = Improvement not needed A. Recovery Advocacy: Delivering your recovery elevator speech, introducing yourself to

peers, making recovery presentations and harnessing culturally-congruent recovery resources

1. Making decisions following the CARES Code of Ethics and using the COPE

Novice -------------------------------------------------------------------------- Expert ______

2. Delivering my CARES recovery elevator speech, introducing myself to peers, telling my recovery (not addiction) story

Novice -------------------------------------------------------------------------- Expert ______

3. Making recovery-oriented systems of care presentations

Novice -------------------------------------------------------------------------- Expert ______

4. Presenting the Science of Addiction and Recovery

Novice -------------------------------------------------------------------------- Expert ______

5. Locating and brokering recovery resources that are culturally suitable to each peer

Novice -------------------------------------------------------------------------- Expert ______

6. Making warm hand-offs to recovery service providers

Novice -------------------------------------------------------------------------- Expert ______

7. Advocating for peers’ recovery with significant others

Novice -------------------------------------------------------------------------- Expert ______

1+2+3+4+5+6+7= ______ divided by 7 = ______ = Recovery Advocacy (RA) Average

B. Recovery Check-Ins: Delivering recovery-oriented, person-directed, and outcome-informed services using relationship enhancement skills (motivational interviewing), peer self-assessment, recovery planning and culturally-congruent resource development

8. Modeling hope

Novice -------------------------------------------------------------------------- Expert ______

9. Assisting peers with self-assessments of strengths, recovery capital, goals and progress

Novice -------------------------------------------------------------------------- Expert ______

10. Conducting Recovery Check-Ins via face-to-face interactions and telephone or other

electronic means

Novice -------------------------------------------------------------------------- Expert ______

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CARES Core Competencies Self-Assessment & Development Plan (cont.)

Novice = Improvement needed -------- Expert = Improvement not needed

11. Affirming/validating the peer’s strengths and building her/his feelings of empowerment

and self-efficacy

Novice -------------------------------------------------------------------------- Expert ______ 12. Listening for stories of change, uplifting change talk and validating progress

Novice -------------------------------------------------------------------------- Expert ______ 13. Incorporating the peer’s theory of change into a recovery plan, goal(s) and activities

Novice -------------------------------------------------------------------------- Expert ______ 14. Using an effective mixture of OARS, e.g., asking no more than two questions followed

by one or two ARS’s, using summaries to organize what’s been said, highlighting change talk, contrasting ambivalence, and shifting to another topic and end interactions

Novice -------------------------------------------------------------------------- Expert ______

15. Documenting interaction notes and facilitating progress reports with significant others

Novice -------------------------------------------------------------------------- Expert ______

8+9+10+11+12+13+14+15 = ______ divided by 7 = ______= Recovery Check-in (RC) Avg.

C. Recovery Group: Conducting recovery groups

16. Establishing a safe and respectful environment

Novice -------------------------------------------------------------------------- Expert ______

17. Administering and interpreting the Outcome Rating Scale, Session (Relationship) Rating Scale, and Self-Completed Overview of Recovery Experience (SCORE) Board

Novice -------------------------------------------------------------------------- Expert ______

18. Modeling relationship enhancement and empowerment skills (OARS+)

Novice -------------------------------------------------------------------------- Expert ______

19. Managing stretches, especially peers who dominate or disrupt the group

Novice -------------------------------------------------------------------------- Expert ______

20. Documenting group notes and facilitating progress reports with significant others

Novice -------------------------------------------------------------------------- Expert ______

16+17+18+19+20= _______ divided by 5 = ______ = Recovery Group (RG) Average

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Relationship Rating Scale

Name: ____________________________________ Date: _____________________________

Relationship: ________________________________________________ Score: ___________

Please rate this relationship’s change potential by placing a mark on the line nearest to the

description that best fits your experience. I didn’t feel understood, I felt understood, respected and respected, and validated. Validation validated.

I----------------------------------------------------------------------I

We did not work on We worked on or or talk about what I talked about what I wanted to work on wanted to work on or talk about. Goals and Topics or talk about.

I----------------------------------------------------------------------I

I did not feel supported and I felt supported and encouraged in my encouraged in change efforts; the my change efforts; role was not Supportive/ the role was a good fit. Encouraging Role a good fit.

I----------------------------------------------------------------------I

Overall, this Overall this relationship may not relationship be the best one for is right for my change efforts. Overall my change efforts.

I----------------------------------------------------------------------I

©2004 Barry L. Duncan. Adapted from the Session Rating Scale, ©2000 by Scott D. Miller, Barry L. Duncan and Lynn D. Johnson.

Examination copy only. Go to www.heartandsoulofchange.com/measures to download the free scales.

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Licensed for personal use only

Session Rating Scale (SRS V.3.0)

Name ________________________Age (Yrs):____ ID# _________________________ Sex: M / F Session # ____ Date: ________________________

Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience.

Relationship

I-------------------------------------------------------------------------I

Goals and Topics

I------------------------------------------------------------------------I

Approach or Method

I-------------------------------------------------------------------------I

Overall

I------------------------------------------------------------------------I

Institute for the Study of Therapeutic Change _______________________________________

www.talkingcure.com

© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson

I felt heard, understood, and

respected.

I did not feel heard, understood, and

respected.

We worked on and talked about what I

wanted to work on and talk about.

We did not work on or talk about what I


Overall, today’s session was right for

me.

There was something missing in the session

today.

The therapist’s approach is a good fit

for me.

The therapist’s approach is not a good

fit for me.

Examination copy only. Download the free scales at www.heartandsoulofchange.com/measures.

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DateType

Nam

e:Johnny B. Good

Start:3‐Jun‐14

Peer Recovery ServiceNum

ber:691903Transfer:

AServer:G

reta ListnerReliable Change Index:

6.6Clinically Significant Change:

Y or N* = Reason

Outcom

e Rating ScaleSession/Relationship Rating Scale

Datefor Service

*IndInt

SocOverall

TotalRel

GAT

AoSOverall

TotalSession 1

4.27.8

8.08.2

28.29.3

10.010.0

10.039.3

Session 23.1

8.16.2

7.424.8

9.69.8

8.17.9

35.4Session 3

3.67.9

8.18.6

28.210.0

9.89.9

9.839.5

Session 44.3

8.28.1

8.429.0

10.09.9

9.69.9

39.4Session 5

5.28.4

7.98.4

29.9Session 6

7.88.1

8.18.6

32.6Session 7

8.88.4

8.28.4

33.8Session 8

8.88.4

8.88.8

34.8Session 9Session 10Session 11Session 12

Partners for Change Outcom

e Managem

ent System

0 5 10 15 20 25 30 35 40

Sess i

1

0 1 2 3 4 5 6 7 8 9 10

Session 1Sessio n

2 3 4 5 6 7 8 9 10

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elper:Greta Listner

Program:Peer Recovery Service

Start Date:Organization:

Num

beNam

eEntry

ProgramID #

(A)ctive(P)lanned Transfer

(U)nplanned Transfer

StartDate

EndDate

ORS

InitialORS

Last# of

SessionsRaw

ChangeReliable ChangeIndex (6+ points)

1Johnny B. G

ooPRS

691903A

7‐Jul‐1415.1

23.03

7.9Y

2Noe N

ohowCRU

328945P

2‐Sep‐1411‐M

ar‐1418.6

23.05

4.4N

3Willit Help

WAC

563247P

10‐Mar‐14

19‐May‐14

32.536.3

93.8

N4

Scooby DooPRS

123456P

11‐Jul‐1413‐Sep‐14

14.219.9

125.7

N5

Swift Taylor

WAC

654321P

14‐Jan‐1428‐Jan‐14

36.432.7

2‐3.7

N6

Mr. T

CRU234567

P11‐Aug‐14

22‐Sep‐1420.3

31.96

11.6Y

7Elvis

PRS918273

U8‐Jan‐14

13‐Jan ‐1411.7

34.22

22.5Y

8Canu Elpm

eCRU

453627A

17‐Jan‐1420.5

19.42

‐1.1N

9Truly Yavis

PRS564738

P14‐Feb‐14

28‐Mar‐14

23.631.3

67.7

Y1011121314151617181920

My Effect Size

ParticipantsAverage

AverageAverage

AveragePlanned ‐ M

et RCI0.99

Active2

21.428.0

5.26.5

2Planned

6StandD

evStandD

evStandD

e vStandD

ev% Planned ‐ M

et RCIUnplanned

18.28

6.573.49

7.5833.3%

Total9

Highest

Highest

Highest

Highest

Unplanned ‐ M

et RCI36.4

36.312.0

22.51

Peer Recovery Support4

Lowest

Lowest

Lowest

Lowest

% Unplanned ‐ M

et RCChange R U

s3

11.719.4

2.0‐3.7

100.0%We All Change

2Total Transfers ‐ M

et R3

% Total Transfers ‐M

et R42.9%

Weeks in Service

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Clinically SignificantChange (RCI &

25+)SRSLast

Notes

N39.0

N40.0

N40.0

N38.7

N36.4

Y40.0

Y38.8

N39.4

Y39.8

Planned ‐ Met CSC

Average2

39.1% Planned ‐ M

et CSCStandD

ev33.3%

1.15Unplanned ‐ M

et CSCHighest

140.0

% Unplanned ‐ M

et CSCLow

est100.0%

36.4Total Transfers ‐ M

et CSC3

Total Transfers ‐Met CSC

42.9%

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ionSession

2S

ession3

Session

4S

ession5

Session

6S

ession7

Session

8S

ession9

Session10

Session11

Session12

Outcom

e Rating Scale Total

n 2Session 3Session 4Session 5Session 6Session 7Session 8Session 9S

ession 10S

ession 11S

ession 12

Individual

0 1 2 3 4 5 6 7 8 9 10

Session 1Session 2

Session 3Session 4

Session 5Session 6

Session 7Session 8

Session 9Session 10

Session 11Session 12

Interpersonal

Social

2 3 4 5 6 7 8 9 10

Overall

33.0

34.0

35.0

36.0

37.0

38.0

39.0

40.0

12

34

56

Session Ratin

10

2.03.04.05.06.07.08.09.0

10.0

Approach/Method or

Supportive/Encouraging Role

0.01.02.03.04.05.06.07.08.09.0

10.0

12

34

56

78

910

1112

Relationship1

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Recovery Action and Progress Group Facilitator Guidelines

1. Group structure guidelines

1.1. Arrive early for group and have Outcome Rating Scales (ORSs) available as participants enter

1.2. For a 1 hour group: limit to 10 or divide into subgroups of 10

1.3. Prevent participant use of rulers before marking the ORS and Group Session Rating Scales (GSRS)

1.4. Provide a folder for each participant containing a RAP Group Handout, pen or pencil, name tag/tent, ORS, GSRS, Self-Completed Overview of Recovery Experience Board (SCORE Board), etc. See the Recovery Action and Progress Group Preparation Checklist.

1.5. Follow the instructions at the top of the RAP Group Handout

1.6. Facilitator’s role: model the OARS. Start the check-in process and use the OARS to assist with other check-ins

1.7. Each participant checks-in with one other participant

1.8. Encourage participants to show their SCORE Boards to illustrate progress over time

1.9. Affirm participant use of the OARS

2. Begin the first group with:

2.1. Thank you for coming today – I am glad to see each one of you.

2.2. Introduce yourself: What about you is important/credible 2.2.1. Peers: use a brief version of your recovery elevator speech and introduction

2.3. Please pull out your Recovery Action and Progress Group Handout. Let’s start by reviewing our group guidelines in the first section after the instructions….

2.4. We’ll do things a little differently than perhaps you’re used to because what is most important are your recovery goals, your view of how you are progressing in your recovery, and how well this group is working for you. I‘d like to get your feedback using a form called the Outcome Rating Scale that others found helpful in making this the best support group possible. Would that be OK with you?

2.5. Anyone forget their glasses or otherwise need help reading or writing? OK, who is willing to help with reading or writing? (Then, ask each participant who indicated needing help) Who among the volunteers would you like to help you?

Recovery Group Facilitator Guidelines www.brauchtworks.com Page 1 of 1

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Brauchtworks Consulting Applying Science to Practice

Recovery Action and Progress Group Preparation Checklist 150719

# = one for each participant * = PCOMS scales (ORS & GSRS) from www.heartandsoulofchange.com ** = from www.brauchtworks.com

1. File folders #....................................................................................................

2. Recovery Action and Progress Group Handouts #** .....................................

3. Outcome Rating Scales (ORS) #* ...................................................................

4. Group Session Rating Scales (GSRS) #* ........................................................

5. SCORE Boards #** .........................................................................................

6. Pens or pencils # ..............................................................................................

7. Centimeter rulers # ..........................................................................................

8. Name tags or tents #: tent works best when using stickers or other rewards .

9. Recommended: Recovery Capital Scale and Plans #** .................................

10. Recommended: Whole Health Action and Management (WHAM) Goal Setting and Plans #** ......................................................................................

11. Recommended: Flip chart pad, stand and markers .........................................

12. Recommended: Clock, if one is not available consider asking for a volunteer

to notify the group 10 minutes before the scheduled end time .......................

13. Recommended: Participant rewards – stickers for attendance, coupons for meeting weekly tasks or progress toward goals, treats, etc. ..........................

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Recovery Capital Scale & Plan

Modified and distributed with the permission of William L. White to George Braucht, Brauchtworks Consulting: www.brauchtworks.com. The original scale is available at

www.williamwhitepapers.com/recovery_toolkit.

Robert Granfield and William Cloud introduced and elaborated on the concept of “recovery capital” in a series of articles and a 1999 book, Coming Clean: Overcoming Addiction without Treatment. They define recovery capital as the volume of internal and external assets that can be brought to bear to initiate and sustain recovery from alcohol and other drug problems. Recovery capital, or recovery capacity, differs from individual to individual and differs within the same individual at multiple points in time. Recovery capital also interacts with problem severity to shape the intensity and duration of supports needed to achieve recovery. This interaction dictates the intensity or level of care one needs in terms of professional treatment and the intensity and duration of post-treatment recovery support services. The figure below indicates how these combinations of problem severity and recovery capital could differ.

High

Recovery Capital

High

Problem Severity /

Complexity

Low

Problem Severity /

Complexity

Low

Recovery Capital

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Modified and distributed with the permission of William L. White to George Braucht, Brauchtworks Consulting: www.brauchtworks.com.

People with high problem severity but very high recovery capital may require fewer resources to initiate and sustain recovery than an individual with moderate problem severity but very low recovery capital. Where the former may respond very well to outpatient counseling, linkage to recovery mutual aid groups and a moderate level of ongoing supervision, the latter may require a higher intensity of treatment, greater enmeshment in a culture of recovery (e.g., placement in a recovery home, greater intensity of mutual aid involvement, involvement in recovery-based social activities), and a more rigorous level of ongoing monitoring and supervision.

Traditional addiction assessment instruments do a reasonably good job of evaluating problem severity and some of the newer instruments improve the assessment of problem complexity (e.g., co-occurring medical/psychiatric problems), but few instruments measure recovery capital. The scale on the following page is intended as a self-assessment instrument to help a client measure his or her degree of recovery capital. The scale can be completed and discussed in an interview format, or it can be completed by the client and then discussed with the professional helper.

References

Cloud, W. (1987). From down under: A qualitative study on heroin addiction recovery. Ann Arbor, MI: Dissertation Abstracts.

Cloud, W. & Granfield, R. (1994). Natural recovery from addictions: Treatment implications. Addictions Nursing, 6, 112-116.

Cloud, W. & Granfield, R. (1994). Terminating addiction naturally: Post-addict identity and the avoidance of treatment. Clinical Sociology Review, 12, 159-174.

Cloud, W. & Granfield, R. (2001). Natural recovery from substance dependency: Lessons for treatment providers. Journal of Social Work Practice in the Addictions, 1(1), 83-104.

Granfield, R. & Cloud, W. (1996). The elephant that no one sees: Natural recovery among middle-class addicts. Journal of Drug Issues, 26(1), 45-61.

Granfield, R. & Cloud, W. (1999). Coming Clean: Overcoming Addiction Without Treatment. New York: New York University Press.

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Recovery Capital Scale

Name: ____________________________________ Date: _______________________

Place a number, 1 to 5 according to the below scale, at the end of each statement

to reflect your current situation.

1 = Strongly Disagree; 2 = Disagree; 3 = Sometimes; 4 = Agree; 5 = Strongly Agree 1. I have the financial resources to provide for myself and my family. ............................................... ____

2. I have personal transportation or access to public transportation. ............................................. ____

3. I live in a home and neighborhood that is safe and secure. ......................................................... ____

4. I live in an environment free from alcohol and other drugs. ...................................................... ____

5. I have an intimate partner supportive of my recovery process. .................................................... ____

6. I have family members who are supportive of my recovery process. .............................................. ____

7. I have friends who are supportive of my recovery process. ........................................................ ____

8. I have people close to me (partner, family members, or friends) who are also in recovery. ...... ____

9. I have a stable job that I enjoy and that provides for my basic necessities. ............................. ____

10. I have an education or work environment that is conducive to my long-term recovery .................... ____

11. I continue to participate in a continuing care program of an addiction treatment program, (e.g.,

outpatient groups, alumni association meetings, etc.) ........................................................... ____

12. I have a professional assistance program that’s monitoring and supporting my recovery process. ____

13. I have a primary care physician who attends to my health problems. .............................................. ____

14. I am now in reasonably good health. .............................................................................................. ____

15. I have an active plan to manage any lingering or potential health problems.............................. ____

16. I am on prescribed medication that minimizes my cravings for alcohol and other drugs. ............ ____

17. I have insurance that will allow me to receive help for major health problems. ........................... ____

18. I have access to regular, nutritious meals. .................................................................................... ____

1 = Strongly Disagree; 2 = Disagree; 3 = Sometimes; 4 = Agree; 5 = Strongly Agree

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1 = Strongly Disagree; 2 = Disagree; 3 = Sometimes; 4 = Agree; 5 = Strongly Agree 19. I have clothes that are comfortable, clean and conducive to my recovery activities. .................. ____ 20. I have access to recovery support groups in my local community. ............................................ ____ 21. I have established close affiliation with a local recovery support group. ................................... ____ 22. I have a sponsor or a special mentor related to my recovery. ................................................. ____ 23. I have access to online recovery support groups. ........................................................................ ____ 24. I have completed or am complying with all legal requirements related to my past. .................... ____ 25. There are other people who rely on me to support their own recoveries. ................................... ____ 26. My immediate physical environment contains literature, tokens, posters or other symbols of

my commitment to recovery. ................................................................................................... ____ 27. I have recovery rituals that are now part of my daily life. ........................................................... ____ 28. I had a profound experience that marked the beginning or deepening of my commitment to

recovery. .................................................................................................................................... ____ 29. I now have goals and great hopes for my future. ........................................................................ ____ 30. I have problem solving skills and resources that I lacked during my years of active

addiction. ................................................................................................................................ ____ 31. I feel like I have meaningful, positive participation in my family and community. ..................... ____ 32. Today I have a clear sense of who I am. ..................................................................................... ____ 33. I know that my life has a purpose. .............................................................................................. ____ 34. Service to others is now an important part of my life. ................................................................ ____ 35. My personal values and sense of right and wrong have become clearer and stronger in

recent years. ............................................................................................................................ ____ Possible Score: 175 ......................................................................................... My Total Score: _______ Items on which I scored lowest: ____________________________________________________ Items on which I scored highest: ____________________________________________________

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Recovery Capital Plan Name: ____________________________________ Date: _______________________ After completing and reviewing the Recovery Capital Scale, below are my recovery goals and activities for the next month. To move closer to each goal, I will increase my recovery capital by doing the following daily and/or weekly activities. Goal # 1: _____________________________________________________________

Activity #1: _______________________________________________________

Activity #2: _______________________________________________________ Activity #3: _______________________________________________________

Goal # 2: _____________________________________________________________

Activity #1: _______________________________________________________


Goal # 3: _____________________________________________________________

Activity #1: _______________________________________________________


Goal # 4: _____________________________________________________________

Activity #1: _______________________________________________________

Activity #2: _______________________________________________________ Activity #3: _____________________________________________________

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Resident Overnight Activities for Recovery (ROAR) Request

The resident completes this form and receives the program counselor’s approval before sending it to the supervising officer at least 10 work days before the first pass date.

A. Since my last pass or pass request I have:

1) followed all program rules ................................................................................. 2) participated in all recovery activities contained in my recovery plan ...................... 3) paid all fees and other financial obligations ......................................................... 4) completed a Resident Monthly Recovery Progress Report for this month ............... 5) consistently modeled recovery behavior ............................................................ If any not checked, explain: _______________________________________________________________________________

_______________________________________________________________________________

B. My proposed overnight recovery pass plans are as follows. The second line describes the recovery

activities that I will complete while on the pass including start & end times & street addresses. Begin Date & Time End Date & Time Residence Street Address HOH and Phone #

1) _____________________________________________________________________________

______________________________________________________________________________

2) _____________________________________________________________________________

______________________________________________________________________________

3) _____________________________________________________________________________

______________________________________________________________________________

4) _____________________________________________________________________________

_____________________________________________________________________________

C. I (check one) approve disapprove the above pass request. If disapproved, here’s why:

_______________________________________________________________________________

_______________________________________________________________________________

Counselor: _________________________________________ Date: ______________________

D. I (check one) approve disapprove of the above pass request. If disapproved, here’s why:

_______________________________________________________________________________

_______________________________________________________________________________

Supervising Officer: ___________________________________ Date: ______________________

Resident: Signature: Date: Resident Cell Phone and/or Email. Enter “None” if applicable: Program Name & Location:

Counselor & Phone Number and/or Email:

Supervising Officer Name: Probation Parole

Supervising Officer Fax # or Email:

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Personal Recovery Information and Discharge Expectations (PRIDE) Report: Resident submit before the last workday of each month

I. Completed by Resident: A. Transfer (discharge) residence plan has has not changed since my last report.

1) Expected transfer date: ______________________________________________________ 2) Transfer to street address: ___________________________________________________ 3) Head of household & phone # ________________________________________________ 4) Job type & employer/school: __________________________________________________ 5) Recovery supports (sponsor, family, peers): ______________________________________

B. Recovery activities completed and progress on last month’s goals: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

C. Recovery goals and activities for the next 30 days: Recovery Goal Associated Activities: Specify when each activity occurs

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

D. Recovery strengths: ___________________________________________________________ ____________________________________________________________________________

E. Recovery needs: ______________________________________________________________ ____________________________________________________________________________

F. Recovery motivation level: 0-10 with 0 = None, 10 = 100% _____ Last month’s level: _____ G. I (check one) do do not plan to go on recovery passes this month. See other side.

II. Drug Tests/Use Since Last Report: Completed by Resident Supervising Officer

Test Date

Enter result: N = Negative; P = Positive; V = Verbal THC Cocaine Alcohol or Other Drugs (List along with result)

III. Other Information. Completed by: Resident Counselor Supervising Officer

Please contact me at your earliest convenience to discuss the below: Yes No An incident with the law Employment or school Alcohol or other drug use

Other: _________________________________________________________________________ _________________________________________________________________________

____________________________________ __________________________________ Resident Signature Date Counselor Signature Date Supervising Officer Signature: ________________________ Date: ______________

Resident: Month __________ Year: _________

Program Name & Location:

Resident: Email Cell and/or House Phone

Counselor & Phone Number and/or Email:

Supervising Officer Name: Probation Parole

Supervising Officer Fax and/or Email:

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UNDERSTANDING OF ALCOHOLISM SCALE 3AC016-130127

William R. Miller & Theresa Moyers Center on Alcoholism, Substance Abuse and Addiction; casaa.unm.edu

My Anonymity Code: ____ ____ ____ ____ Today’s Date: ___________________ My Scores: Disease Model = ______________ Psychosocial Model = ______________ Heterogeneity Model = ______________ Moral/Spiritual Model = ______________ Interpreting Your Results

1. Highest score suggests your model preference = easiest to work with like-minded people 2. Disease vs Heterogeneity: Strong negative correlation

a. Goal-choice: abstinence vs. moderation b. Goal-selection: impose vs. negotiate c. Motivational-assistance: traditional confrontation vs motivational enhancement

3. Heterogeneity score: implies your willingness to use a variety of recovery resources 4. Moral/Spiritual score: suggests your preference/tolerance for faith-based resources

Professional Development Goal: Equally high scores on all four scales!

Based on Moyers, T. B. & Miller, W. R. (1993). Therapists’ conceptualization of alcoholism:

Measurement and implications for treatment. Psychology of Addictive Behaviors, 7, 238-245. Disease Model

Reflect adherence to the disease model of alcoholism and characterological flaws in alcoholics (e.g., “Drinking alcoholics are liars and cannot be trusted.”) Associated with imposing, instead of negotiating, treatment goals (helper determined vs. client choice) and an unwillingness to consider a moderation goal (as opposed to abstinence).

Psychosocial (Learning) Model

Believe alcoholism is influenced by cultural experience, familial experience, or both. Tend to be more willing to allow client choice and actively support pursuing client-determined goals. Also have been shown to be active in retention efforts like making phone calls and/or sending letters, even after treatment has been interrupted.

Heterogeneity Model

Reject the homogeneity (similarity) of alcoholics and believe that they show diverse symptoms, have diverse reasons for drinking, and require different strategies for recovery. Have a significant, negative correlation with Disease Model beliefs.

Moral/Spiritual Model

Believe alcoholics have weak morals and negative characterological factors (e.g., self-centeredness) and that recovery requires reliance on a spiritual faith. Strong correlation with the Disease Model beliefs, especially in people who are in recovery.

Distributed by George S. Braucht, LPC www.brauchtworks.com

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Recovery Check-In Overview 160712

Goal: Provide assertive continuing care interactions before, during and after treatment - research shows that these contacts improve the likelihood of sustained, meaningful engagement in treatment and long-term recovery. Contacts may be made while peers/clients are on waiting lists, between appointments or groups, and as follow-ups to no-shows. The check-in also serves as a reminder of the next scheduled treatment or other social service appointment thereby reducing no-shows while also promoting timely resource utilization and recovery community integration.

Suggested Frequency: The below are suggested as minimum interaction frequencies. However, the frequency is best determined by each peer/client and her/his needs.

First 8 weeks: 1X a week; Second 8 weeks: 1X every 2 weeks; Months 5+: 1X a month Eight Step Recovery Check-Ins

Issues brought up by the peer take precedence over any pre-determined contact outline. 1. Acknowledge peer then introduce yourself and clarify your role 2. Complete the Outcome Rating Scale (ORS) 3. Complete and discuss Craving or Set-back/Symptom Ratings = primary

reason(s) for seeking service 4. Discuss Recovery Capital and Plan or WHAM 5. Complete the Session/Relationship Rating Scale (S/RRS) and discuss what will make

the next interaction more useful 6. Schedule the next Recovery Check-In and remind or assess commitment to attend

the next treatment/other appointment 7. Summarize major topics and next week’s activities/goals as stated by the participant 8. If not completed during the check-in, transfer ORS, Craving, and S/RRS ratings to the

Self-Completed Overview of Recovery Experience (SCORE) Board.

Additional Recovery Check-In materials available at www.brauchtworks.com/changeagenttoolkit: 1. SCORE Board 2. Recovery Capital Scale and Plan 3. WHAM Facilitator Guide 4. Recovery Check-In Practice Guide: Initial Telephone Contact 5. Recovery Check-In Practice Guide: Ongoing Telephone Contact

References

1. Duncan, B. (2005). What’s right with you. Deerfield Beach, FL: Health Communications. Peer and professional versions of the ORS, SRS and RRS are available free at www.heartandsoulofchange.com.

2. Mid-America Addiction Technology Transfer Center. (2008). The Arkansas continuing care program telephone monitoring and adaptive counseling – clinician manual. Kansas City, MO: Author.

3. Scott, C. K, & Dennis, M. L. (2003). Recovery Management Checkups: An Early Re-Intervention Model. Chicago, IL: Chestnut Health Systems.

Brauchtworks Consulting Applying Science to Practice www.brauchtworks.com Email: [email protected]

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Recovery Check-In Form 160712

Peer: _______________________________________________ Peer # ___________________________ Check-In Provider: ____________________________________ Site: ______________________________ Next Treatment or Other Social Service Agency Appointment: Date: ______________ Time: _____________ Attempts: Date [YYMMDD]; Time [HHMM); Type (Phone, Text, Email, Face-To-Face, Other: [Specify])

#1: ___________________ #2: ___________________ #3: ___________________ #4: ___________________ Contact Date: __________________ Start and End Times: __________________ Type: __________________ ******************************************************************************************* I. Acknowledge peer/client and, if needed, clarify your role: Ask: What’s right with you today?

II. Outcome Rating Scale: Individual: _____ Interpersonal: _____ Social: _____ Overall: _____ Total: _____ ORS Clinical Cutoff = 25: Adult, 28: Adolescent & 32: Child

III. Craving/Set-back/Symptom Rating = Primary reason(s) for seeking service. 0 = Did not think about alcohol or other drugs (AOD); 10 = Used AOD ________

IV. Recovery Capital Scale and Plan/WHAM: Progress since last check-in

V. S/R Rating Scale: Relat.: ____ Goals/Top: ____ Support/Encour: ____ Overall: _____ Total: _____ S/RRS Adult Clinical Cutoff = 36

VI. Next Recovery Check-In: Day: _____________ Date: _______________ Time: ______________ Remind about her/his next treatment or other social service agency appointment and ask if assistance is needed

VII. Summarize the main topics the peer/client discussed during this interaction and next weeks’ tasks/activities

VIII. Transfer ORS, S/RRS, Craving Rating and goals progress to the SCORE Board

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WH

AM

Self-Com

pleted Overview

of Recovery Experience (SC

OR

E) Board: N

ame: ______________

*Interaction Types: Individual, Group, R

ecovery Check-In, Phone, E

-Video or Text, O

ther Interaction # &

Type* 1

2 3

4 5

6 7

8 9

10 11

12 13

WH

AM

#1 Goal:

Date

Risk Score

Outcom

e Rating

Scale (OR

S) Score

Tasks = What:

Craving R

ating (0-10)

H

ow M

uch:

Session/Group/R

elationship R

ating Scale Score

How

Often:

Write an “O

” in the column below

to show each of your O

RS scores.

When:

WH

AM

#2 Goal:

Tasks = W

hat:

How

Much:

#1 Goal Task #

H

ow O

ften:

#1 Goal Task #

#2 G

oal Task #

When:

# 2 Goal Task #

Write a brief description of your goals and task(s) in the right colum

n. Above, enter task # as they are com

pleted and w

hen goal is accomplished.

Adult O

RS

Clinical C

utoff = 25

Adult SR

S/GSR

S/RR

S C

linical Cutoff = 36

40

35

30

25

20

15

10

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Brauchtw

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Applying Science to Practice

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Email: george@

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Recovery Action and Progress Group Handout 150719

Instructions: Begin group with everyone completing a (1) Outcome Rating Scale and 2) updating her or his SCORE Board. 3) Review the Group Guidelines. 4) One participant does a Recovery Check-In with another participant using the Relationship Enhancement OARS until everyone has checked in. 5) End group by completing then discussing today’s Group Session Rating Scale scores. Be sure to add the GSRS score to your SCORE Board.

A. Group Guidelines

1. Turn off cell phones, computers, etc., and notify someone if you must leave the room. 2. Vegas Rules: Say “Vegas Rules” before you say something that you do not want repeated

outside of this group. 3. No fixing! Instead, share what recovery activities have worked for you by using “I…”

statements. 4. What other guidelines will help make this a safe and respectful place for you?

B. Recovery Check-In. Use the Relationship Enhancement OARS (below) to ask… 1. What’s right with you today? 2. What is your ORS score? What progress did you make since your last group on your

recovery goals? May show your Self-Completed Overview of Recovery Experience Board (SCOREboard).

3. From 0-10, what is your highest craving level since the last group, with 0 = Never thought

of using alcohol or other drugs; 10 = Used 4. Do you have a safe and sober place to stay? 5. Would you like more group time today?

Relationship Enhancement OARS

Open-Ended Questions: Express concern, interest, puzzlement, etc.; Who, What, How Affirmation/Validation: Affirm appreciation for the other person and identify his or her

strengths; “You stayed sober last weekend!” instead of, “How did you manage to avoid drinking?” “You are concerned about…”

Begin with “You…” not “I” Describe behaviors Attend to solutions instead of problems Attribute interesting qualities to the person Focus on a strength or attribute, not the lack of something or what was not done

Reflective Listening: Make statements about what you heard the other person say instead of asking questions

Begin with: “You think (feel)…,” “You’re wondering if…,” “So you feel (think)…,” Summaries: Short, clear statements that organize what’s been said; Use “and” instead of “but”

Brauchtworks Consulting Applying Science to Practice www.brauchtworks.com Certified PCOMS and Recovery Coach Training

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Outcome Rating Scale (ORS)

Name ________________________Age (Yrs):____ Sex: M / F Session # ____ Date: ________________________ Who is filling out this form? Please check one: Self_______ Other_______ If other, what is your relationship to this person? ____________________________

Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels. If you are filling out this form for another person, please fill out according to how you think he or she is doing.

ATTENTION: TO INSURE SCORING ACCURACY PRINT OUT THE MEASURE TO INSURE THE ITEM LINES ARE 10 CM IN LENGTH. ALTER THE FORM UNTIL THE LINES PRINT THE CORRECT LENGTH. THEN ERASE THIS MESSAGE.

Individually (Personal well-being)

I----------------------------------------------------------------------I

Interpersonally

(Family, close relationships)

I----------------------------------------------------------------------I

Socially (Work, school, friendships)

I----------------------------------------------------------------------I

Overall

(General sense of well-being)

I----------------------------------------------------------------------I

The Heart and Soul of Change Project _______________________________________

www.heartandsoulofchange.com

© 2000, Scott D. Miller and Barry L. Duncan


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Group Session Rating Scale (GSRS)

Name _____________________________________ Age (Yrs):_______________________ ID# _____________________________ Sex: M / F Session # ____________ Date: ________________________________________________

Please rate today’s group by placing a mark on the line nearest to the description that best fits your experience.

Relationship

I----------------------------------------------------------------------I

Goals and Topics

I----------------------------------------------------------------------I

Approach or Method

I----------------------------------------------------------------------I

Overall

I----------------------------------------------------------------------I

The Heart and Soul of Change Project _______________________________________

www.heartandsoulofchange.com

© 2007, Barry L. Duncan and Scott D. Miller

I felt understood, respected, and

accepted by the leader and the group.

I did not feel understood, respected, and/or

accepted by the leader and/or the group.

We worked on and talked about what I


We did not work on or talk about what I


Overall, today’s group was right for me—I felt like a part of the group.

There was something missing in group

today—I did not feel like a part of the group.

The leader and the group’s approach are

a good fit for me.

The leader and/or the group’s approach are/is

not a good fit for me.


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