[State] Network of Oxford Houses

Spring 2007 Self-Administered Questionnaire

This is a self-administered Confidential set of questions approved by Oxford House, Inc.. Please do not sign your name or identify yourself on this questionnaire.

Please check or answer only ONE response for each question.

1. What is your current age? years. 2.. Sex o Male o Female

3. Are you presently employed? o Yes o No 4. Ever served in Military Service? o Yes o No

5. Race ? o White o Black o Hispanic o Oriental o Native American o Pacific Islander o Other

6. What is your marital status? o Never Married o Married o Separated o Divorced o Widowed

7. What is your current gross (before taxes & insurance are taken out) monthly income? $ .

8. How many years of school have you completed? ______.

9. How many times have you tried to get sober or straight counting this time? .

10. How long have you been sober or straight this time? Indicate number of days, weeks, months or years .

Name of last Treatment Facility

11. How many times have you ever been in detox without continuing an outpatient or residential treatment program? ______

12. How many times have you been in a residential treatment program?______

13. How many times have you ever been arrested while intoxicated? How much total time have you spent in jail? ______Longest period in jail?______(days or months or years)

14. Have you ever been homeless? o Yes o No

If “yes,“ indicate how many times? ______times. If yes, longest period of time was ?

15. Where did you last live (other than a residential treatment facility) before coming to Oxford House?

o apartment; o owned house; o rented house; o rented room/ SRO hotel; o jail; o mental hospital; o VA hospital; o half-way house; o homeless

16. How important has Oxford House been to your sobriety? o somewhat important o moderately important

o very important o insignificant o not really sure

17.Would you recommend Oxford House to other alcoholics or drug addicts in early recovery?

o Yes o No o Uncertain

18. Approximately how many AA or NA meetings do you attend each week?

____AA meetings; ____NA meetings

19. Do you now go to counseling in addition to AA or NA? o Yes o No

20. In general how would you rate your health? o very good; o pretty good; o not so good o quite poor

21. Name of Oxford House you now live in.______

22. What month and year did you move into Oxford House? ______

Thank you for your help in this survey. It will help Oxford House document its story so that the Oxford House concept and system of operation can be shared with others around the country.