Get Free Addiction Treatment when you Join our Research Study

First name*

Last name*

Email address*

example@example.com

Cell Phone Number*

Date of birth*

MonthDayYear

Please tell us your race and ethnicity (select those that apply):*

What is your gender?*

What are your preferred pronouns?*

He/HimShe/HerThey/them

Do you consider yourself*

What’s your highest level of education?*

Please provide an emergency contact, including their name, number, and your relationship to them. *

Current Employment Status?*

Full-time job (35+ hours)Part-time job(s) (irregular hours)Contractor / temp agencyUnemployed

What is your living situation for the next 2 months?*

Live in my own house or apartmentLive in the house or apartment of an immediate family member (parent or sibling)Live in the house or apartment of another family member other than a parent or siblingLive in the house or apartment of a friendLive in a nursing home, long term care facility, or hospitalCurrently homeless or will be within 2 months"Couch Surfing" – bouncing from place to place, not sure where I will be from day to day/week to weekOther

Are you currently in an outpatient or inpatient treatment program for addiction? Please note, if you are already in another treatment program, this will disqualify you from joining.*

YesNo

Do you have health insurance?

YesNo

Who is your insurance provider?*

If other, please specify your insurance provider?

Are you currently experiencing any of the following? (Our program may not be safe for people experiencing these conditions.)*

Severe seizuresStrokePregnancyN/A – None of the Above

Are you currently experiencing any of the following? (Our program may not be safe for people with certain mental health conditions such as schizophrenia or suicidality).*

PsychosisSchizophreniaSuicidalityN/A – None of the Above

How do you typically take your preferred substance?*

SnortSmokeInjectOther

How long have you been using?*

How often do you use?*

Rate on a scale of 1-5: I have a problem with drugs and alcohol*

Rate on a scale of 1-5: I would like to change something about my alcohol or drug use.*

Rate on a scale of 1-5: I am already working on my problem with alcohol and drugs*

Do you have a smartphone?*

YesNo

What kind of smartphone do you have?*

iPhoneAndroid

What kind of data plan do you have?*

Unlimited data and textingLimited data and textingNo data plan but I have access to WifiNo data plan, no access to Wifi

Do you know how to install apps on your phone?*

YesNo

Are you comfortable using text messaging?*

YesNo

Do you know how to take a screenshot on your phone?*

YesNo

Have you ever used zoom or another video meeting program such as Facetime?*

YesNo

Can you access treatment for the full next 2 months (e.g. no expected jail time, inpatient stay)? Please note, answering no will result in disqualification from the program.*

YesNo

Are you able to commit about 4 hours a week to this recovery program?*

YesNo

Mailing Address *

Street Address

Street Address Line 2

CityState

Zip Code

If there are any special instructions for delivery of mail (gate code, entry code, etc.) please let us know:

Please check the times when you ARE available to attend meetings (e.g. when you don’t have work, childcare).*

What days and times are you NOT AVAILABLE to have an appointment scheduled? Please consider your work schedule and all other commitments such as childcare.*

Do you have any involvement currently with the criminal justice system or other legal obligations in the next two months that would prevent you from attending meetings?*

YesNo

Are there any circumstances in your life that would prevent you from attending meetings? If yes, what are they?*

You will be asked to attend virtual group therapy meetings. Can you commit to attending a 1-hour group meeting twice a week?*

YesNo

Part of the program is completing short daily goals in a phone app for 10 minutes each day. Do you commit to completing these goals daily?*

YesNo

Part of the program requires that you self-administer drug tests once a week. We ask our members to perform these tests for data analysis, and to hold themselves accountable during their recovery. Do you commit to participating in these tests? *

YesNo

Study Inclusion and Exclusion Criteria

INCLUSION CRITERIA To be eligible to participate in the study, prospective participants must: 1) Be 18 years of age or older; 2) Have a substance use disorder (SUD) or documented high-risk use history for stimulants or cannabis, confirmed by DSM-5 criteria; 3) Have stated interest in reducing and/or stopping use; 4) Have and be able to use a smartphone and agree to download and use the Affect app as part of treatment and study-related procedures; 5) Have a health insurance plan (or Medicaid) to ensure that participants have access to medical care if needed; 6) Be English speaking and have reading capacity sufficient to understand explanations of study procedures and the informed consent to participate; 7) Be able to freely give informed consent and be willing to electronically sign the digital informed consent to participate in the study; 8) Be willing to comply with study procedures, including use of the Affect app consistent with the study protocol and therapeutic activities.
EXCLUSION CRITERIA Individuals will be precluded from enrolling in the study if they endorse (or if there is documentation of) any of the following conditions. Already enrolled participants will be withdrawn from study participation upon the emergence of any excluded condition (except pregnancy): 1)Serious medical diagnoses (e.g., seizure, stroke, other chronic condition); 2) Serious mental illness (e.g., schizophrenia, active suicidality); 3) Moderate- to severe-level opioid use disorder; 4) Pregnancy; 5) Be concurrently receiving other behavioral or pharmacological services for the treatment of an SUD; 6)Have pending legal action or other situation that could inhibit consistent participation in the study or in study activities. Additionally, if your application is not accepted or you choose not to participate after your questionnaire has been submitted, any information you provide will be destroyed.

By submitting this form, you agree to be contacted by Affect via phone, email, and text messaging.

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Affect Recovery Study Questionnaire

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Participating in the Affect program