1
We value your input and would like to get feedback on your journey !
Graduating / Completing the Program Terminated Opted Out
Did you start the program from In-Custody (jail) or Out-of-Custody? ___________
1. In your opinion, what are YOU most proud of in your life today?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
2. What challenges did you face while in the program?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
3. Why did you originally choose to come into this program?
To get out of / avoid jail time Treatment available
Support/structure Resources available
Family / child custody Other_________________________________
4. Prior to this program, have you had any contact with any of the following?
Probation/Parole Outpatient treatment
Inpatient treatment Another Drug/Treatment Court program
Child Protective / Welfare Services
5. What aspects of the Court supervision do you feel was helpful to you (Please check ALL
that you feel motivates you)?
Positive interaction with the Judge, praise Sobriety coins
Phasing up ceremonies Extra support meetings
Rewards/Incentives for doing well for the week (egg draw, Making Cents, blessing rings)
Referrals to other types of support groups, skill-building classes, resources in general
Writing assignments / Essays / Calendar exercises
Having my entire team there to answer any questions I had or get feedback
Treat of jail Threat of losing custody of my children
EXIT INTERVIEW FOR
CLARK COUNTY DRUG COURT / DOSA DRUG COURT
2
Other: _________________________________________________________________
Other: _________________________________________________________________
6. What aspects of the Court supervision do you feel was LESS helpful to you in motivating
you (Please check ALL that apply)?
Positive interaction with the Judge, praise Sobriety coins
Phasing up ceremonies Extra support meetings
Rewards/Incentives for doing well for the week (fortune cookies, PayDay candy bars, Smarties)
Referrals to other types of support groups, skill-building classes, resources in general
Writing assignments / Essays / Calendar exercises Work Crew / Community Service
Having my entire team there to answer any questions I had or get feedback
Treat of jail Threat of losing custody of my children
Other: _________________________________________________________________
Other: _________________________________________________________________
7. If money was no object, what reward / incentives would have been helpful to you / your
family?
8. While you have been in this program, have you been referred to Inpatient treatment?
No
I wasn’t referred but I went to inpatient on my own
Yes, and completed inpatient
Yes, but never went to inpatient
Yes, and went to inpatient but did not complete
Yes, and went to inpatient twice
List Inpatient Treatment Center Name(s) and length of stay (# of months)
____________________________________________________________________________
Treatment / Education Services Aspect of This Program
3
9. Please check off the name of the treatment center and/or education services you or your
children attended during drug court AND the type of the treatment or class. For example:
( MH (mental health), SUD (drug & alcohol, Parenting Classes/Family Therapty (Circle of
Security, Celebrating Families, Child Parent Psychotherapy (CPP), MAT (medication-
assisted treatment),?
Lifeline Connections________________ Community Services NW ___________________
Veteran’s Administration_____________ Columbia River Mental Health ______________
Cowlitz Indian Tribe________________ Children’s Home Society____________________
MAT: Ideal Options __________________ Children’s Center _________________________
REACH Too / REACH Center classes: ______________________________________________
Other: _________________________________________________________________________
10. What aspect of treatment do you feel really HELPED you? Please list/explain your
answer below. (if you did not go, please write N/A)
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
11. What aspect of treatment do you feel was LEAST helpful to you? Please list/explain your
answer below.
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
12. Please describe some skills or information you specifically learned from parenting class
and/or therapy services that you feel really HELPED you and your family the most?
Please list/explain your answer below. (if you did not go, please write N/A)
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
13. Was there anyone on the team that you didn’t understand what their role was? Do you
have a suggestion for how we can communicate that better to new participants?
______________________________________________________________________________
Personal Experience in This Program
4
14. Please select each member on the Team that you felt comfortable contacting to ask
questions and/or to share personal information with.
Treatment Counselor / Case Manager Child Social Worker
Specialty Court Coordinator Defense Attorney
Coordinator’s Assistant Family Specialist / Therapist
Other Counselor (MH, DV, etc) Judge
Parenting Class Educator Recovery Coach / Mentor / Recovery Support Specialist
CASA Foster Parent Mentor
Other (please specify) _____________________
I don’t feel comfortable sharing personal information with anyone at this time
15. If you received any violations/sanctions/responses while you were in the program,
please list what it was and if you felt it helped on a scale of 1 – 5 (1=didn’t help, 5 =
helped me a lot). For example, create a 2 week calendar, 4
Response: ___________________________ Scale: 1 2 3 4 5
Response: ___________________________ Scale: 1 2 3 4 5
Response: ___________________________ Scale: 1 2 3 4 5
Response: ___________________________ Scale: 1 2 3 4 5
Response: ___________________________ Scale: 1 2 3 4 5
Response: ___________________________ Scale: 1 2 3 4 5
16. If you received any rewards / incentives while you were in the program, please list what
it was and if you felt it helped on a scale of 1 – 5 (1=didn’t help, 5 = helped me a lot).
For example, fortune cookie, 5
Reward : ___________________________ Scale: 1 2 3 4 5
Reward : ___________________________ Scale: 1 2 3 4 5
Reward : ___________________________ Scale: 1 2 3 4 5
Reward : ___________________________ Scale: 1 2 3 4 5
Reward : ___________________________ Scale: 1 2 3 4 5
17. Anything else you thought was really helpful to get you focused or back on track?
____________________________________________________________________________
5
18. Did you receive any extra services or help to overcome any barriers while in this
program? YES NO
If YES, what did you receive? ________________________________________________
________________________________________________________________________
19. Which community support groups do you attend (please check all that apply)?
Alcoholics Anonymous Mentor activities
Narcotics Anonymous Alanon / Codependency anonymous
Church / Youth Group Sponsor meetings
Bible Study Gender-specific meetings
SMART Recovery Grief / Loss meetings
Domestic Violence support groups Medication-Assisted Recovery meetings
Organized clean and sober activities (bowling, softball, retreats, campouts, etc.)
Other (please specify) _____________________________________
20. How long have you been in this program (# of months)? _________
21. About how long from the time you were arrested did it take to actually get in and start
Drug Court (best guess in # of weeks): ___________________________________
22. How did you first learn / know about Drug Court?
attorney cell mate / jail worker friend / family
other _________________________________________________________
23. Did you choose to have a mentor while in the program? If so, about how often did you
talk or meet up on average and what did you like most about it?
______________________________________________________________________
______________________________________________________________________
24. If you were in charge of the program, what suggestions or changes would you make?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
25. If you are opting out of the program, why are you leaving and is there anything the
court / team could have done differently to change your mind to stay in?
______________________________________________________________________
______________________________________________________________________
6
Look at What I’ve Been Able to Accomplish
Name __________________________________ Date ________________
While participating in the Drug Court/ DOSA Program, I got help with the following services (please check
ALL that apply)!
Transportation
DONE STILL NEED
HELP WITH
Transportation
Obtaining Driver’s License
Ignition Interlock
DOL hearing (habitual offender status)
Fines in Collections
Employment
DONE STILL NEED
HELP WITH
Employment/Resume/Job search/Interview
skills/interview clothing
Housing
DONE STILL NEED
HELP WITH
Clean and sober housing w/child(ren)
Clean and sober housing w/no kids
Education
DONE STILL NEED
HELP WITH
Education/GED
Finances/Better Budgeting
Time Management/Organization/Scheduling
Stress Management
Parenting Classes
Learn Child/Infant/Adult CPR & First Aid
Learning about or how to use computers
Creative Problem solving
Domestic Violence Classes/Anger Management
Pro-Social
DONE STILL NEED
HELP WITH
Having fun sober (hobby, exercise)
Recovery environment
Family/peer-to-peer support/mentor
Health & Wellness
DONE STILL NEED
HELP WITH
Medications (access / copay)
Dental health care insurance / issues
Medical health Care/ issues (diabetes, Hep C, etc.)
Family Planning information (birth control,
pregnancy services, etc.)
Mental Health Counseling, for me
Mental Health Counseling, for child(ren)
Grief and Loss counseling/support
Trauma counseling/support
Family counseling/classes
Nutrition/ Cooking
Fitness/Weight management
Healthy Relationships
Childcare while in services
Legal/Other
DONE STILL NEED
HELP WITH
Obtaining State ID card
Dependency case
Parenting Plan through the courts
Divorce information
Reduce fines & fees - for
(Circle one) District Court or Superior Court
Cellphone assistance
Letter of support/recommendation for:
_________________________________________________
Other (please specify)____________________
