Alumni Feedback Form

Name:	*
Discharge Date:	* (MM/DD/YY)
Clean Date:	* (MM/DD/YY)
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:	*

*Must answer each of these questions below before submitting form.*
Are you currently sober?	Yes No
Are you currently clean (except for prescribed medications)?	Yes No
If you were discharged from one of our residential programs, did you keep your initial appointment with the aftercare program (for example, Outpatient/Intensive Outpatient Program, halfway house, partial care program)?	Yes No
Are you still attending the aftercare program?	Yes No
Are you attending AA or NA meetings or any other self-help groups?	Yes No
Are you employed?	Yes No
Are you attending school or any training program?	Yes No
Since leaving Turning Point, have you been referred to or admitted to any other program for addiction treatment?	Yes No
Do you need additional treatment now?	Yes No
Since leaving Turning Point, have you been arrested or charged with any alcohol or drug related offenses?	Yes No
Would any of your family members benefit from help in coping with the effects of addiction on your family?	Yes No
How can we contact them?
Is there anything else you'd like us to know?

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