The National Drug Court Institute
0-342900Exit Interview00Exit InterviewPlease place an “X” in the appropriate box of why you are leaving the programGraduating the Program: FORMCHECKBOX Terminated: FORMCHECKBOX Opting Out: FORMCHECKBOX 0114300Entry Process00Entry ProcessHow did you first learn that this program was an option for you? FORMCHECKBOX Attorney FORMCHECKBOX Friend FORMCHECKBOX In custody FORMCHECKBOX Probation Officer FORMCHECKBOX Family FORMCHECKBOX Court FORMCHECKBOX Peer FORMCHECKBOX Other: _________________________2. Did you start this program in custody or were you out of custody and had pending your charges? FORMCHECKBOX In Detention/Jail when I entered FORMCHECKBOX Out of custody (Detention/Jail) when I entered FORMCHECKBOX In residential treatment3. Why did you originally choose to come into this program? FORMCHECKBOX To get out of jail FORMCHECKBOX Treatment available FORMCHECKBOX Less incarceration time FORMCHECKBOX Support/structure FORMCHECKBOX Financial benefit FORMCHECKBOX Keep license FORMCHECKBOX Resources available FORMCHECKBOX No conviction FORMCHECKBOX Other ___________________________________________________________114300135890Court Aspect of This Program00Court Aspect of This Program4. 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 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX During orientation, were program benefits explained to you? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Other: _______________________________________6. What aspects of the court supervision do you feel is helpful to you (Please check ALL that you feel motivates you)? FORMCHECKBOX Positive interaction with the Judge FORMCHECKBOX Sobriety coins FORMCHECKBOX Phasing up ceremonies FORMCHECKBOX Rewards/Incentives for doing good reaching goals FORMCHECKBOX Community Service/Work Crew FORMCHECKBOX Extra recovery support groups FORMCHECKBOX Peer support specialist FORMCHECKBOX Home visits FORMCHECKBOX Writing assignments/Essays FORMCHECKBOX Increasing court reporting FORMCHECKBOX Detention/Jail or threat of Detention/JailAny additional comments on how or why something helped you?________________________________________________________________________________________________________________________________________________________________________________________________________________________7. What aspects of the court supervision do you feel is LESS helpful to you in motivating you (Please check ALL that apply)? FORMCHECKBOX Positive interaction with the Judge FORMCHECKBOX Sobriety coins FORMCHECKBOX Phasing up ceremonies FORMCHECKBOX Rewards/Incentives for doing good reaching goals FORMCHECKBOX Community Service/Work Crew FORMCHECKBOX Extra recovery support groups FORMCHECKBOX Peer support specialist FORMCHECKBOX Home visits FORMCHECKBOX Writing assignments/Essays FORMCHECKBOX Increasing court reporting FORMCHECKBOX Detention/Jail or threat of Detention/JailAny additional comments on how or why something helped you?________________________________________________________________________________________________________________________________________________________________________________________________________________________0174625Treatment Aspect of This Program00Treatment Aspect of This Program8. What aspect of treatment do you feel really HELPED you? Please list/explain your answer below. _________________________________________________________________________________________________________________________________________________________________________________________________________9. What aspect of treatment do you feel was LEAST helpful to you? Please list/explain your answer below. _________________________________________________________________________________________________________________________________________________________________________________________________________10. Which of the following made it hard to be open and honest in treatment? FORMCHECKBOX Fear of stigma/peers judging me FORMCHECKBOX Trust in sharing sensitive information with providers FORMCHECKBOX Providers not recognizing daily struggles of my life FORMCHECKBOX Providers not understanding my culture 11. While you have been in this program, have you been referred to Inpatient treatment? FORMCHECKBOX No FORMCHECKBOX I wasn’t referred but I went to inpatient on my own FORMCHECKBOX Yes, and completed inpatient FORMCHECKBOX Yes, but never went to inpatient FORMCHECKBOX Yes, and went to inpatient but did not complete FORMCHECKBOX Yes, and went to inpatient twiceList Inpatient Treatment Center Name and length of stay (# of months) _____________________________________________________________________________12. Prior to this program, have you been under the supervision of any of the following? FORMCHECKBOX Probation/Parole FORMCHECKBOX Out-patient treatment FORMCHECKBOX Inpatient treatment FORMCHECKBOX Other treatment court program FORMCHECKBOX Social Services/CPS2286000Personal Experience in This Program00Personal Experience in This Program11. 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. FORMCHECKBOX Treatment Counselor/Case Manager FORMCHECKBOX Child Worker / CASA FORMCHECKBOX Treatment Court Coordinator FORMCHECKBOX Defense Attorney FORMCHECKBOX Law Enforcement FORMCHECKBOX Prosecuting Attorney FORMCHECKBOX Probation Officer FORMCHECKBOX Other Counselor (MH, DV, etc) FORMCHECKBOX Judge FORMCHECKBOX Educator FORMCHECKBOX I don’t feel comfortable sharing with anyone at this time FORMCHECKBOX Other (please specify) _____________________________________12. Please tell us about a time when you or someone else was not respected in this program.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________13. Did you receive sanction(s) while in this program?Please check ALL that apply to you. Community Service Work CrewExtra meetingsJail DetentionWritten assignmentCurfew EHMYES FORMCHECKBOX # of hrs. ____ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NO FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other (please specify) ___________________________________________________14. Did you generally understand why people received sanctions in this program? FORMCHECKBOX Yes FORMCHECKBOX No15. Did you receive rewards while in this program? FORMCHECKBOX YES FORMCHECKBOX NO Please share your ideas for rewards that would be helpful. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________16. Was there ever a time you were not treated fairly in this program? Please explain your answer._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________17. What difficulties/barriers have you experienced while in this program? FORMCHECKBOX Transportation FORMCHECKBOX Childcare FORMCHECKBOX Obtaining driver’s license FORMCHECKBOX Finances FORMCHECKBOX Education FORMCHECKBOX Employment FORMCHECKBOX Mental Health Counseling FORMCHECKBOX Lack of family/peer support FORMCHECKBOX Making appointments FORMCHECKBOX Obtaining State ID FORMCHECKBOX Medications FORMCHECKBOX Sober housing FORMCHECKBOX Relating to/trust of staff FORMCHECKBOX Medical/Dental issues FORMCHECKBOX Other counseling/classes FORMCHECKBOX Changing attitude/beliefs FORMCHECKBOX Recovery environment FORMCHECKBOX Neighborhood conditions FORMCHECKBOX Other (please specify) _____________________________________Did any of these difficulties make it hard to stay in this program?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________18. Did you receive any extra services or help to overcome some of these barriers while in this program? FORMCHECKBOX YES FORMCHECKBOX NO If YES, what did you receive? ________________________________________________ _________________________________________________________________________19. Which community support groups do you attend? FORMCHECKBOX Alcoholics Anonymous FORMCHECKBOX Narcotics Anonymous FORMCHECKBOX Church / Youth Group FORMCHECKBOX Bible Study FORMCHECKBOX SMART Recovery FORMCHECKBOX Domestic Violence support FORMCHECKBOX Organized sober/recovery activities (bowling, softball, retreats, campouts, etc) FORMCHECKBOX Other (please specify) _____________________________________20. How did community support help you in this program?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________21. In your opinion, what are YOU most proud of in your life today? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________22. What comments and/or changes would you like us to know about or think about for the program?_________________________________________________________________________________________________________________________________________________________________________________________________________ 23. If you are opting out, why are you leaving the program? _________________________________________________________________________________________________________________________________________________________________________________________________________ Thank you! ................
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