Settings
Time zone
(UTC-12:00) International Date Line West
(UTC-11:00) Coordinated Universal Time-11
(UTC-10:00) Hawaii
(UTC-09:00) Alaska
(UTC-08:00) Tijuana, Baja California
(UTC-08:00) Pacific Time (US and Canada)
(UTC-07:00) Arizona
(UTC-07:00) Chihuahua, La Paz, Mazatlan
(UTC-07:00) Mountain Time (US and Canada)
(UTC-06:00) Central America
(UTC-06:00) Central Time (US and Canada)
(UTC-06:00) Guadalajara, Mexico City, Monterrey
(UTC-06:00) Saskatchewan
(UTC-05:00) Bogota, Lima, Quito
(UTC-05:00) Eastern Time (US and Canada) (Form default)
(UTC-05:00) Indiana (East)
(UTC-04:00) Asuncion
(UTC-04:00) Atlantic Time (Canada)
(UTC-04:00) Caracas
(UTC-04:00) Manaus
(UTC-04:00) Georgetown, La Paz, San Juan
(UTC-04:00) Santiago
(UTC-03:30) Newfoundland and Labrador
(UTC-03:00) Brasilia
(UTC-03:00) Cayenne
(UTC-03:00) Buenos Aires
(UTC-03:00) Montevideo
(UTC-02:00) Coordinated Universal Time-02
(UTC-02:00) Greenland
(UTC-02:00) Mid-Atlantic
(UTC-01:00) Azores
(UTC-01:00) Cape Verde Is.
(UTC) Coordinated Universal Time
(UTC) Greenwich Mean Time : Dublin, Edinburgh, Lisbon, London
(UTC) Monrovia, Reykjavik
(UTC) Casablanca
(UTC+01:00) Amsterdam, Berlin, Bern, Rome, Stockholm, Vienna
(UTC+01:00) Belgrade, Bratislava, Budapest, Ljubljana, Prague
(UTC+01:00) Brussels, Copenhagen, Madrid, Paris
(UTC+01:00) Sarajevo, Skopje, Warsaw, Zagreb
(UTC+01:00) West Central Africa
(UTC+02:00) Athens, Bucharest, Istanbul
(UTC+02:00) Beirut
(UTC+02:00) Cairo
(UTC+02:00) Minsk
(UTC+02:00) Harare, Pretoria
(UTC+02:00) Helsinki, Kyiv, Riga, Sofia, Tallinn, Vilnius
(UTC+02:00) Jerusalem
(UTC+02:00) Windhoek
(UTC+03:00) Amman
(UTC+03:00) Baghdad
(UTC+03:00) Kuwait, Riyadh
(UTC+03:00) Moscow, St. Petersburg, Volgograd
(UTC+03:00) Nairobi
(UTC+03:30) Tehran
(UTC+04:00) Abu Dhabi, Muscat
(UTC+04:00) Baku
(UTC+04:00) Port Louis
(UTC+04:00) Tbilisi
(UTC+04:00) Yerevan
(UTC+04:30) Kabul
(UTC+05:00) Tashkent
(UTC+05:00) Ekaterinburg
(UTC+05:00) Islamabad, Karachi
(UTC+05:30) Chennai, Kolkata, Mumbai, New Delhi
(UTC+05:30) Sri Jayawardenepura
(UTC+05:45) Kathmandu
(UTC+06:00) Astana
(UTC+06:00) Dhaka
(UTC+06:30) Yangon (Rangoon)
(UTC+07:00) Bangkok, Hanoi, Jakarta
(UTC+07:00) Krasnoyarsk
(UTC+07:00) Novosibirsk
(UTC+08:00) Beijing, Chongqing, Hong Kong S.A.R., Urumqi
(UTC+08:00) Irkutsk
(UTC+08:00) Kuala Lumpur, Singapore
(UTC+08:00) Perth
(UTC+08:00) Taipei
(UTC+08:00) Ulaanbaatar
(UTC+09:00) Osaka, Sapporo, Tokyo
(UTC+09:00) Seoul
(UTC+09:00) Yakutsk
(UTC+09:30) Adelaide
(UTC+09:30) Darwin
(UTC+10:00) Brisbane
(UTC+10:00) Canberra, Melbourne, Sydney
(UTC+10:00) Guam, Port Moresby
(UTC+10:00) Hobart
(UTC+10:00) Vladivostok
(UTC+11:00) Magadan, Solomon Is., New Caledonia
(UTC+12:00) Auckland, Wellington
(UTC+12:00) Coordinated Universal Time+12
(UTC+12:00) Fiji Is., Marshall Is.
(UTC+12:00) Petropavlovsk-Kamchatsky
(UTC+13:00) Nuku'alofa
(UTC+13:00) Midway Island, Samoa
Recovery Assessment Scale
View a printable version of this form here.
Full Name
Member Cardinal ID Number
Provider Name
*
Please select a value...
A Better Path, Inc.
Addictive Recovery Medical Services
Alamance Academy, LLC
Ariel Community Care, LLC
B and D Integrated Health Services
Caramore Community, Inc.
Carolina Community Support Services, Inc.
Carolina Enhancement Services, LLC
Carolina Therapeutic Services First, Inc
Carolinas Medical Center-Main (FAC)
Central Community Services, LLC
Community Care Service, LLC
Community Counseling Services, PC
Crandell's Enterprises, Inc.
DAYMARK Recovery Services, Inc.
DAYMARK Recovery Services, Inc. - CRC Unit - Cabarrus County
Easter Seals UCP North Carolina & Virginia, Inc.
Empowerment Quality Care Services
Family Innovations, LLC
Family Preservation Services of North Carolina, Inc.
Fidelity Community Support Group, Inc.
First Step Community Services LLC
First Step Support Services, LLC
Freedom House Recovery Center, Inc
Genesis Project 1, Inc.
Hope Haven
InnerVision, Inc.
Insight Human Services
Little Gerald Services, LLC
Lutheran Family Services in the Carolinas
Matchbox Health Services Corporation
Monarch
New Beginnings Day Treatment Center, LLC
NSC Behavioral Concepts, LLC
Person Centered Partnerships, Inc.dba Amara Wellness, Inc.
Peter-Elst, LLC
PQA Healthcare, Inc.
Recovery Innovations, Inc.
RHA Health Services NC, LLC
RHA Health Services, Inc.
RHA Behavioral Health, NC, LLC
S&H Youth and Adult Services, Inc.
Securing Resources for Consumers, Inc.
Serenity Rehabilitation Services
Spring Life Behavioral Care, LLC.
Standards-Based Solutions Behavioral Health Consulting & Management LLC
Sunrise Clinical Associates, PLLC
TGH Behavioral Health Services, Inc.
Top Priority Care Services, LLC
Trinity Behavioral Healthcare PC
Trinity Wellness & Community Care, LLC
UNC Faculty Physicians
United Quest Care Services, LLC
Vision Behavioral Health Services, LLC
Walkers Group Home, Inc.
Date Completed
Peer Bridger
Peer Bridger Pilot Site
Evaluation Type
Please select a value...
Initial Evaluation
Re-evaluation
Please answer these items on an agreement scale where 1 is "Strongly Disagree" and 5 is "Strongly Agree".
Strongly
Disagree
Not
Sure
Strongly
Agree
Disagree
Agree
1. I have a desire to succeed
*
1
2
3
4
5
2. I have my own plan for how to stay or become well
*
1
2
3
4
5
3. I have goals in life that I want to reach
*
1
2
3
4
5
4. I believe I can meet my current personal goals
*
1
2
3
4
5
5. I have a purpose in life
*
1
2
3
4
5
6. Even when I don't care about myself, other people do
*
1
2
3
4
5
7. Fear doesn't stop me from living the way I want to
*
1
2
3
4
5
8. I can handle what happens in my life
*
1
2
3
4
5
9. I like myself
*
1
2
3
4
5
10. I have an idea of who I want to become
*
1
2
3
4
5
11. Something good will eventually happen
*
1
2
3
4
5
12. I'm hopeful about my future
*
1
2
3
4
5
13. Coping with my mental illness is no longer the main focus of my life
*
1
2
3
4
5
14. My symptoms interfere less and less with my life
*
1
2
3
4
5
15. My symptoms seem to be a problem for shorter periods of time each time the occur
*
1
2
3
4
5
16. I know when to ask for help
*
1
2
3
4
5
17. I am willing to ask for help
*
1
2
3
4
5
18. I ask for help, when I need it
*
1
2
3
4
5
19. I can handle stress
*
1
2
3
4
5
20. I have people I can count on
*
1
2
3
4
5
21. Even when I don't believe in myself, other people do
*
1
2
3
4
5
22. It is important to have a variety of friends
*
1
2
3
4
5
Personal Confidence and Hope Score
Sum of items 7, 8, 9, 10, 11, 12 & 19
7
35
Willingness to ask for Help Score
Sum of items 16, 17 & 18
3
15
Goal and Success Orientation Score
Sum of items 1, 2, 3, 4 & 5
5
25
Reliance on Others Score
6, 20, 21 & 22
4
20
Not Dominated by Symptoms Score
13, 14 & 15
3
15
Personal Confidence and Hope Score
Sum of items 7, 8, 9, 10, 11, 12 & 19
Willingness to ask for Help Score
Sum of items 16, 17 & 18
Goal and Success Orientation
Sum of items 1, 2, 3, 4 & 5
Reliance on Others Score
6, 20, 21 & 22
Not Dominated by Symptoms Score
13, 14 & 15
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