RECOVERY MAINTENANCE CHECK-IN


(Last Name:) 
(Firs Name:) 
(AGE:) 
(Gender:) 
(ID#:) 
(Date of Last Contact:) 
(Current Call Date) 
(Name of Interviewer) 
(Collateral Contact:) 
(Phone Number) 
**************************************************************************************************************************************

GREETING: 
Hello, my name is with[court] . I am calling to see how you are 
doing and whether there is anything we can help you with. Is this a good time to talk? 
IF YES, Well we want to do whatever we can to help you maintain the gains you have made. 
What is one of the best things that has happened to you since our last contact? OR discharge from drug court? 
IF NO, when would be a good day and time to call you back? We won’t take much of your time. We just want to 
see how you are doing and if we can be of any help. 


 

Thank you I will call back then.


(InterviewerName) 
(Court) 
(Call Back Date) 
(Call Back Time) 
HOUSING 


1. Are you still living at [address]: 


 1a. IF NO, what is the new address? 


2. Is this still the best phone number to reach you? 


2a. IF NO, [New number]: 


3. Is this a good stable place for you to live? [FOR EXAMPLE COUCH SURFING, LIVING WITH FRIENDS, MAY DENOTE 
UNSTABLE LIVING ARRANGEMENTS. A SAFE AREA MEANS LOW CRIME/DRUGS] 


 
3a. IF NO, what changes are you likely to make in your living arrangement? 


4. How, if at all, can we be of assistance to you with your housing? 


MI PROMPTS: Affirm for stable, healthy living arrangements. 
Affirm for any positive changes Reflect any dissatisfaction/problems and feelings about them


(CurrentAddy) Unchecked
(CurrentAddress) 
(NewAddress) 
(BestPhone) Unchecked
(BestPhoneNum) 
(NewBestPhoneNum) 
(LivingArrange) Unchecked
(HousingAssist) Unchecked
4. Owns a home in a safe area


(4. Owns a home in a safe area) Unchecked
Wants assistance with housing - Yes 


(Wants assistance with housing - Yes ) Unchecked
No


(No) Unchecked
3. Renting in a safe area


(3. Renting in a safe area) Unchecked
2. Staying with relatives/friends; housing unstable


(2. Staying with relatives/friends; housing unstable) Unchecked
1. Homeless


(1. Homeless) Unchecked
STATUS: [CHECK ONE] MI LEVEL:[CHECK ONE]

5. Maintaining positive change


(5. Maintaining positive change) Unchecked
4. In process of making change


(4. In process of making change) Unchecked
3. Getting ready, committed to change


(3. Getting ready, committed to change) Unchecked
2. Thinking about making change


(2. Thinking about making change) Unchecked
1. No intentions of making change


(1. No intentions of making change) Unchecked
page 1 of 7


DOCUMENT IMPRESSIONS/FOLLOW UP PLANS/RECOMMENDATIONS ON HOUSING 


(HousingRecommendations) 
FAMILY/SOCIAL STATUS


(FSSFamily1) Unchecked
1. How are things going for you with your family? For example, your marriage, kids, or other close relationships?


(FSSFamily2) Unchecked
2. Are your family members or others close to you experiencing issues or problems that worry you or are making things difficult 
for you?


(FSSFamily3) Unchecked
3. What assistance from us would be helpful for these problems? 


(FSSFamily4) Unchecked
4. What family members, friends, or others close to you care about your well-being? 


(FSSFamily5) Unchecked
5. Can you turn to these people when things are difficult and you need someone to talk to? 


(FSSFamily6) Unchecked
6. What assistance from us, would be helpful for these problems? 

MI PROMPTS: Affirm good coping skills, strategies. 
Affirm for any positive changes 
Affirm for addressing problems. Reflect the feelings/difficulties being experienced.

4. Maintaining stable relationships 


(4. Maintaining stable relationships ) Unchecked
Help requested with Family/Social - Yes 


(Help requested with Family/Social - Yes ) Unchecked
No


(No) Unchecked
3. Some new problems but being addressed 


(3. Some new problems but being addressed ) Unchecked
2. Significant problems causing instability for client


(2. Significant problems causing instability for client) Unchecked
1. Problems exist, no supports,/estranged from family 


(1. Problems exist, no supports,/estranged from family ) Unchecked
5. Maintaining positive change


(5. Maintaining positive change) Unchecked
4. In process of making change


(4. In process of making change) Unchecked
3. Getting ready/committed to change


(3. Getting ready/committed to change) Unchecked
2. Thinking about making a change 


(2. Thinking about making a change ) Unchecked
1. No intentions of making change


(1. No intentions of making change) Unchecked
page 2 of 7

STATUS: [CHECK ONE] MI LEVEL:[CHECK ONE]


HEALTH STATUS


(HS1) Unchecked
1. How has your health been? For example, have you had any illness or injuries?

2. Have you seen a medical professional such as a doctor, nurse, or physician assistant, since our last call?


(HS2a) 
2a. IF YES, for what problem? 

Yes 


(Yes ) Unchecked
No


(No) Unchecked
(HS2) Unchecked
Yes 


(Yes ) Unchecked
No


(No) Unchecked 
2c. IF YES, list medications


(HS4) Unchecked
(HS4) Unchecked
5. Are you taking any prescribed medications for this?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
(HS5a) 
4. How are you doing emotionally? For example, are you feeling really down or really anxious about anything? 


(HS6) Unchecked
3. How about any health problems or injuries to family members or those close to you that you worry about?

IF NO, PROCEED TO QUESTION 7.

 5a. IF YES, list medications

Yes 


(Yes ) Unchecked
No


(No) Unchecked 
2b. Are you on any medications for this?


(HS2c) 
5b. Are you taking this as it was prescribed?


(HS6) Unchecked
6. Have there been any traumatic events experienced by you or those close to you since our last contact? [e.g. violence, 
injury, accidents]


(HS7) Unchecked
7. What kind of help or resources, if any, do you feel you need for your health issues?

MI PROMPTS: Express empathy for any new illness, health problems or trauma Affirm for good health -related items and for good 
self-care. Affirm for medication compliance

4. No significant problems/concerns


(4. No significant problems/concerns) Unchecked
5. Maintaining positive change


(5. Maintaining positive change) Unchecked
4. In process of making change


(4. In process of making change) Unchecked
3. Getting ready, committed to change


(3. Getting ready, committed to change) Unchecked
2. Thinking about making change


(2. Thinking about making change) Unchecked
1. No intentions of making change


(1. No intentions of making change) Unchecked
page 3 of 7

DOCUMENT IMPRESSIONS/FOLLOW UP PLANS/RECOMMENDATIONS ON FAMILY/SOCIAL STATUS


(FSSRecommendations) 
STATUS: [CHECK ONE] MI LEVEL:[CHECK ONE]

3. Minor problem but being addressed


(3. Minor problem but being addressed) Unchecked
2. Health problems are threatening recovery


(2. Health problems are threatening recovery) Unchecked
1. Health is fragile, client not coping well 


(1. Health is fragile, client not coping well ) Unchecked
Help requested for health/trauma problems - Yes 


(Help requested for health/trauma problems - Yes ) Unchecked
No


(No) Unchecked

2. Let's talk about any use of alcohol or other drugs.


(Substance3) Unchecked
3b. How many drinks per day?


(Substance3b) 
3c. IF NO, go on to question #6


(Substance4) Unchecked
6. Have you used any drugs that were not prescribed for you since our last contact?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
(Substance6a) 
5a. IF YES, how many days ago did this occur?


(Substance6) Unchecked
5. Have you been able to stop drinking?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
(Substance5a) 
4. What kind of help or support have you tried for this?


(Substance5) Unchecked
7. Have you sought any kind of help or support for this?

IF No, why not?

page 4 of 7

DOCUMENT IMPRESSIONS/FOLLOW UP PLANS/RECOMMENDATIONS ON HEALTH STATUS


(HealthStatusRecommendations) 
SUBSTANCE USE


(Substance1) Unchecked
1a. IF YES, how is your recovery going?

1d. Would you like us to set up some time with a treatment counselor?

1. Are you on supervision (Probation/parole)?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
IF NO, proceed to question 2


(Substance1ayes) 
1c. Are there others you have found to be supportive in your recovery efforts?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
6a. IF YES, when was the last time you used?(days)

6b. How much did you use?


(Substance6b) 
6c. IF NO, go on to question #9


(Substance7) Unchecked
3a. IF YES, when was your last drink?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
Go to question 9


(Substance2) Unchecked
3. Have you used any alcohol since our last contact?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
(Substance3a) 
1b. Are you going to meetings? Are you in touch with your sponsor?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
IF NO, why not?


STATUS: [CHECK ONE] MI LEVEL:[CHECK ONE]

4. No use since last contact


(4. No use since last contact) Unchecked
Yes 


(Yes ) Unchecked
No


(No) Unchecked
10a. IF YES, Would you like some help with this?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
MI PROMPTS: Affirm for days abstinent 
Affirm skills/strategies being used to support abstinence/ attendance at self-help meetings 
Reflect feelings surrounding any struggles 
Affirm for asking for or accepting any help

5. Maintaining positive change


(5. Maintaining positive change) Unchecked
4. In process of making change


(4. In process of making change) Unchecked
3. Getting ready, committed to change


(3. Getting ready, committed to change) Unchecked
2. Thinking about making change


(2. Thinking about making change) Unchecked
1. No intentions of making change


(1. No intentions of making change) Unchecked
DOCUMENT IMPRESSIONS/ FOLLOW UP PLANS/RECOMMENDATIONS FOR SUBSTANCE USE:

FINANCIAL/OCCUPATIONAL STABILITY


(fin1) Unchecked
(fin2) Unchecked
2. Has anything changed since our last call? [e.g. new job, raise, lost job etc.] 


(fin2achange) 
(fin2aother) 
2a. IF YES, What has changed? New employment/Job Other

page 5 of 7

8. Have you been able to stop using?


(Substance8) Unchecked
Yes 


(Yes ) Unchecked
No


(No) Unchecked
9b. As you think about this, are there changes that might improve this situation?

10. How about any gambling, are you doing any? 


(Substance10) Unchecked
Yes 


(Yes ) Unchecked
No


(No) Unchecked
3.Has relapsed but currently abstinent, using supports


(3.Has relapsed but currently abstinent, using supports) Unchecked
2. In relapse but seeking help


(2. In relapse but seeking help) Unchecked
1. In relapse, not seeking help


(1. In relapse, not seeking help) Unchecked
Help requested for Substance Use- Yes 


(Help requested for Substance Use- Yes ) Unchecked
No


(No) Unchecked
Help requested for Gambling Use- Yes 


(Help requested for Gambling Use- Yes ) Unchecked
No


(No) Unchecked
(SubstanceStatusRecommendations) 
1. How are you doing financially? Are you able to support yourself? 

8a. IF YES, for how many days? 


(Substance8ayes) 
8b. IF NO, Would you be willing to talk to a counselor?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
9a. IF YES, How is their substance use affecting you? 

9. Are any family members or others close to you using? 


(Substance9) Unchecked

(fin4) Unchecked
Help requested for Employment Problems - Yes


(Help requested for Employment Problems - Yes) Unchecked
No


(No) Unchecked
(fin3) Unchecked
4. Significant Improvement e.g. new job


(4. Significant Improvement e.g. new job) Unchecked
5. Maintaining positive change


(5. Maintaining positive change) Unchecked
Yes 


(Yes ) Unchecked
No


(No) Unchecked
2b. How have their problems with law enforcement affected you?

4. Where would you like to be financially/job wise one year from now? 


(fin5assist) 
(fin5) Unchecked
Yes 


(Yes ) Unchecked
No


(No) Unchecked
(Criminal1c) 
2b. Do you feel it is better of worse than before? 

3. How about any family members or others close to you--do any of their financial problems worry you or cause you to feel 
stressed? 

3. No change, finances are stable


(3. No change, finances are stable) Unchecked
2. No change, finances are poor, having trouble making ends meet


(2. No change, finances are poor, having trouble making ends meet) Unchecked
1. Unemployed, financially unstable 


(1. Unemployed, financially unstable ) Unchecked
2. Thinking about making change


(2. Thinking about making change) Unchecked
1. No intentions of making change


(1. No intentions of making change) Unchecked
DOCUMENT IMPRESSIONS/ FOLLOW UP PLANS/RECOMMENDATIONS FOR FINANCIAL/OCCUPATIONAL STABILITY:

CRIMINAL ACTIVITY


(Criminal1) Unchecked
5. How can we be of assistance to you in regard to these issues? 

MI PROMPTS Affirm for financial stability/stable employment. 
Affirm for having goals 
Reflect feelings around any concerns 
Reflect feelings associated with job positives

STATUS: [CHECK ONE] MI LEVEL:[CHECK ONE]

4. In process of making change


(4. In process of making change) Unchecked
3. Getting ready, committed to change


(3. Getting ready, committed to change) Unchecked
(FinancialStatusRecommendations) 
1. Have you had any contact with law enforcement or the court system since our last call?

1a. IF YES, what happened?

1b. Were you charged with anything?

Yes 


(Yes ) Unchecked
No


(No) Unchecked
2a. IF YES, what kind of problems?

page 6 of 7


(fin4) Unchecked
1c. What was the violation?


(Criminal2) Unchecked
2. Have any family or close friends had problems with law enforcement?


FOR ALL THAT ARE POSITIVE, REPEAT THEM AND SAY, It sounds like these things are going well for you


(positives) 
FOR ALL THAT ARE CAUSING PROBLEMS, REPEAT THOSE ISSUES AND SAY, it sounds like you might need some help with:


(negitives) 
Do you agree? 

Yes


(Yes) Unchecked
No


(No) Unchecked
(other) 
(IF YES,) 
(Neg-yes-date) Specify When
[Name or Person] will get back to you 


(Neg-no-date) Specify When
DOCUMENT IMPRESSIONS/ FOLLOW UP PLANS/RECOMMENDATIONS FOR CRIMINAL ACTIVITY:

OVERALL SUMMARY 
Is there any other information you would like us to know; good things that are happening or problems that are occurring with you or 
family members or others close to you?

IF NO HELP IS NEEDED, SPECIFY TIMEFRAME FOR NEXT CALL


(PhoneNum) 
STATUS: [CHECK ONE] MI LEVEL:[CHECK ONE]

4. No new legal encounters, arrests/charges


(4. No new legal encounters, arrests/charges) Unchecked
5. Maintaining positive change


(5. Maintaining positive change) Unchecked
4. In process of making change


(4. In process of making change) Unchecked
3. Getting ready, committed to change


(3. Getting ready, committed to change) Unchecked
2. Thinking about making change


(2. Thinking about making change) Unchecked
1. No intentions of making change


(1. No intentions of making change) Unchecked
(CriminalStatusRecommendations) 
CONFIRM PHONE NUMBER FOR NEXT CALL

EXPRESS YOUR APPRECIATION FOR CLIENT'S TIME, AND ASSURE THEM THEY CAN CALL FOR FURTHER ASSISTANCE AT ANY 
TIME. 

AFFIRM CLIENT FOR CONTINUED EFFORTS AT RECOVERY!

page 7 of 7


(Criminal3) Unchecked
3. Have any family or close friends had problems with law enforcement?

MI PROMPTS Affirm for no further criminal activity 
Express concern; reflect feelings/problems associated with further legal involvement. 
Affirm for taking responsibility to resolve any legal problems

3. Family/friends in legal trouble but not impacting client


(3. Family/friends in legal trouble but not impacting client) Unchecked
2. New arrest, no charges filed


(2. New arrest, no charges filed) Unchecked
1. New arrest, charges filed


(1. New arrest, charges filed) Unchecked
Help requested for legal problems - Yes


(Help requested for legal problems - Yes) Unchecked
No


(No) Unchecked