Recovery Capital Assessment
We're so glad you are participant in recovery support services at Alano Club. Please feel out the following survey to help us ensure we can keep all of our services free via grant funding. All answers and information will be kept 100% private and confidential.
Name
First Name Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Gender Identity
Race
Ethnicity
Select all that apply:
I identify as a person in recovery from substance use disorder I identify as a person in recovery from mental health I have attended SUD treatment in the past I have attended MH treatment in the past I am currently experiencing homelessness I am a veteran I am a student I currently live in a recovery residence I am currently in SUD treatment I am currently in MH treatment I have used medications for SUD previously I am currently using medications for SUD

Please answer each of the following statements to the best of your ability.*

	Strongly Agree	Agree	Somewhat Agree	Somewhat Disagree	Disagree	Strongly Disagree
There are more important things to me in life than using substances
In general, I am happy with my life
I have enough energy to complete the tasks I set for myself
I am proud of the community I live in and feel a part of it
I get lots of support from friends
I regard my life as challenging and fulfilling without the need for using drugs or alcohol
My living space has helped to drive my recovery journey
I take full responsibility for my actions
I am happy dealing with a range of professional people
I am making good progress on my recovery journey

Recovery Capital Assessment