GRAFTON COUNTY DEPARTMENT OF CORRECTIONS
FOCUSED INTENTIONAL REENTRY AND RECOVERY
(FIRRM) PROGRAM
Pre-Screening Application
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The Focused Intentional Reentry and Recovery (FIRRM) Program is an intensive outpatient substance use treatment program for individuals during incarceration. All participants must complete the attached application and agree to the following participant expectations before their enrollment.
Practice Cultural Humility
Cultural humility is entering a relationship with another person(s) to honor their beliefs, customs, and values. It entails ongoing self-exploration, self-critique, and a willingness to learn from others.
What's said stays in the group.
Feeling safe in the group is very important to a successful group experience. Confidentiality is the shared responsibility of all group members and leaders. Please keep group discussions confidential and the names and identities of other group members confidential.
Member Participation
A FIRRM participant must commit to attending daily group classes and scheduled individual sessions. If you have an illness that prohibits you from coming to class, you must report to class and inform the program staff of your illness to receive an excused absence. However, excused absences may require additional days of FIRRM participation to be eligible for a completion certificate. Only three unexcused absences will be allowed in 100 days. If a participant cannot attend FIRRM for more than two weeks due to a disciplinary sanction, classification level, or extended illness, restarting the program may be required to earn a completion certificate.
Homework is an essential component of FIRRM participation, and it is one of the best methods for program staff to evaluate an individual's progress. If the homework is consistently not completed, the program staff may recommend discharge or require extended program participation.
During group classes, individuals are expected not to engage in disruptive activities such as (crosstalk, private conversations, or yelling). A participant may be removed from class anytime program staff determine an individual's behavior is undermining the learning of others. Individuals may be suspended or discharged from the FIRRM program if the behavior continues throughout several group classes.
Demographics:
Name: Date of Birth:
Street Address: City/Town:
State: Zip Code:
County of Residence: SSN#:
Home Phone: Cell Phone:
Please answer all questions honestly, or risk program disqualification and/or termination.
1. Have you ever been formally diagnosed with a substance use disorder?
2. Have you ever been formally diagnosed with a mental health disorder?
3. At what age did you start using drugs or alcohol?
4. Have you ever experienced an overdose? If yes, how long ago?
5. Have you ever injected drugs?
What substances did you How often did you use What was your method of When did you use it last
use prior to incarceration? them? use
Example: Fentanyl Twice daily Injection 5 days
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1. During the past twelve months, did you ever notice that the same amount of drugs or alcohol YES NO
didn’t have the same effect as they used to or that you had to drink more alcohol or use more
drugs to get the same effect?
2. During the past twelve months, have you wanted or tried unsuccessfully to cut down or YES NO
control your substance use?
3. During the past twelve months, have you spent a great deal of time either obtaining, using, or YES NO
recovering from the effects of alcohol or drugs?
4. During the past twelve months, have you had cravings, or a strong desire or urge alcohol or YES NO
drugs?
5. During the past twelve months, has your recurrent use of alcohol or drugs resulted in a failure YES NO
to fulfill major role obligations at work, school, home?
6. During the past twelve months, have you continued to use alcohol or drugs even though this YES NO
use has contributed to problems with others, such as arguments with friends or family or
physical fights, etc.?
7. During the past twelve months, have you given up any work, family, or leisure activities YES NO
because of your use of a substance?
8. During the past twelve months, have you used alcohol or drugs when your use could be YES NO
putting yourself in physical danger (use while driving, participating in sports, operating heavy
machinery, etc.)?
9. During the past twelve months, have you continued to use alcohol or drugs despite knowing YES NO
that you have a physical or emotional problem that is either caused by or made worse by your
substance use?
10. During the past twelve months, have you used more alcohol or drugs or used for a longer YES NO
time than you had planned?
11. During the past twelve months, have you experienced physical distress when you quit YES NO
drinking or taking drugs, or have you found yourself taking alcohol or a drug to avoid withdrawal
symptoms?
Why are you interested in participating in the FIRRM Program?
Acknowledgment of Limits to My Privacy
I understand my records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records 42 CFR Part 2 and Health Insurance Portability and Accountability Act of 1996 (HIPPA), 45 CFR Pts. 160 & 164 and cannot be disclosed without my written consent.
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Applicant Signature Date