Welcome to Archangel Advocacy LLC. Please print this form and bring it to your first appointment.

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 Cope to Hope – Archangel Advocacy LLC

 

Welcome! We are honored to walk beside you on your journey. At Cope to Hope, part of Archangel Advocacy LLC, we offer compassionate, peer-led support grounded in trauma-informed care, cultural humility, and respect for your lived experience. This is a safe space where your voice matters, your story is honored, and healing begins with connection.

 

As part of our commitment to diversity, equity, and inclusion (DEI), we ask a few optional questions to help us better understand and support your unique identity and experience. Your answers help us create a more affirming, respectful, and empowering environment.

 

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Trauma-Informed DEI Interview Questions:

 

1. How would you describe your cultural background, identity, or community, and are there aspects you would like us to honor or be aware of during our sessions?

(This helps us understand and affirm cultural safety and individual preferences.)

 

2. Have you ever felt misunderstood or judged in past support services based on your race, gender identity, disability, religion, housing staus, or lived experience? What would safety and respect look like to you here?

(This question centers the client's past experiences and preferences moving forward.)

 

3. What support practices or communication styles make you feel most respected, heard, and empowered—especially during times of stress or vulnerability?

(This builds trust and honors client-led care and emotional safety.)

 

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INTAKE QUESTIONAIRE

 

PART 1: CLIENT INTAKE & ANONYMITY TRUST FORM

 

Fictional Peer Name Form & Anonymity-Based Rapport Builder

 

Peer Counseling Program Name: "COPE TO HOPE"

 

Session 1: Trust & Identity Building

 

Purpose:

This form supports anonymity and fosters early and long term rapport. Clients create a fictional identity ("recovery name") to increase safety, express freely, and track their healing journey over 90 days.

 

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CLIENT FICTIONAL NAME & SAFETY CHECK-IN FORM

 

1. Date: _________________________

 

2. Preferred Fictional Name for Sessions: _________________________

 

3. Preferred Pronouns (optional): _________________________

 

4. Emergency Contact (only used if you consent):

  Name: ____________________  Phone: ____________________

  ☐ I consent to this contact being used in an emergency

  ☐ I do not consent

 

5. Current Living Situation:

 

☐ Street

 

☐ Shelter

 

☐ Vehicle

 

☐ Couch-surfing

 

☐ Transitional housing

 

☐ Other: _________________________

 

6. Safety Questions:

 

Do you feel physically safe today? ☐ Yes ☐ No

 

Do you have access to food today? ☐ Yes ☐ No

 

Do you have a phone or way to contact services? ☐ Yes ☐ No

 

7. What made you reach out today?

(Short response)

 

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8. Top 3 Values You Want to Grow Over 90 Days:

☐ Honesty ☐ Peace ☐ Health ☐ Stability ☐ Connection

☐ Confidence ☐ Recovery ☐ Faith ☐ Purpose ☐ Self-love

☐ Other: ________________________

 

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PART 2: MOTIVATIONAL INTERVIEW — FROM COPE TO HOPE

 

Title: Motivational Habit Builder & Strength-Focused Interview

 

A. STAGES OF CHANGE

 

Which stage are you in today?

☐ Just thinking about change

☐ I want to try changing

☐ I’ve already started

☐ I’ve had some setbacks

☐ I’ve been staying consistent

 

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B. FROM COPE TO HOPE: HABIT TRACKING TOOL

 

1. What are your current coping methods?

☐ Using drugs/alcohol ☐ Avoiding people

☐ Sleeping a lot ☐ Getting angry ☐ Humor

☐ Writing ☐ Faith ☐ Music ☐ Other: ___________

 

2. What small habits give you hope?

☐ Talking to someone ☐ Meetings ☐ Journaling

☐ Prayer ☐ Walking ☐ Drawing

☐ Remembering good moments ☐ Gratitude list

 

3. Weekly Habit Goals (check 1–3 to start):

☐ Write 1 thing I’m grateful for daily

☐ Attend 1 AA/NA/Faith group per week

☐ Write down 1 thing I want to change

☐ Text/call someone I trust each week

☐ Write 3 things I did right this week

 

4. What has helped you stay clean and sober or safe even once before?

 

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5. What’s one new idea you’re willing to try this week?

 

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6. Name 2 strengths you see in yourself today:

 

1. 

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2.

 

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PART 3: WELLNESS RECOVERY ACTION PLAN -INTRODUCTORY

 

WRAP – ANONYMOUS CLIENT NAME: ________________

 

(Use fictional name to protect identity)

 

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A. DAILY WELLNESS TOOLS: What helps you feel well enough to function?

 

☐ Coffee/tea in the morning

☐ Clean clothes

☐ Safe space to rest

☐ Talking with a friend

☐ Journaling or drawing

☐ Meetings

☐ Listening to calming music

☐ Medication (if applicable)

☐ Prayer or spiritual focus

 

Other: __________________________________________________________

 

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B. EARLY WARNING SIGNS (check all that apply):

 

☐ Feeling irritable

☐ Hearing voices

☐ Using or craving substances

☐ Isolating from others

☐ Not sleeping

☐ Feeling “too good” or manic

☐ Feeling hopeless

☐ Seeing things that aren’t there

 

What can you do when you notice these?

☐ Talk to peer support

☐ Go to a meeting

☐ Ask for help

☐ Use grounding (breathing, holding ice)

☐ Call a warm line

☐ Other: ___________________________

 

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C. CRISIS PLAN:

 

When things get really hard, who can help? (List anonymously, like “my sponsor,” “case worker at DESC,” or “pastor”, Anrchangel Advocacy Volunteers )

 

1. 

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2. 

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What helps me feel safer when in crisis?

☐ Being around people

☐ Being alone

☐ Walking

☐ Hospital (if voluntary)

☐ Prayer

☐ Art or music

 

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D. POST-CRISIS & REBUILDING PLAN

 

After a crisis, what helps me get back to wellness?

☐ Clean clothing/shower

☐ Meeting with peer

☐ Journaling my feelings

☐ Eating a meal

☐ Reflecting on what happened

☐ Breathing or mindfulness

 

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E. SIGNATURE PAGE (ANONYMOUS)

 

Recovery Name (Fictional): ______________________

Peer Advocate: ______________________

Date: ______________________

 

> This WRAP Plan is confidential and shared only with the peer supporter unless otherwise agreed. You have the right to adjust, revoke, or request changes at any time.This form will not be in the custody of Archangel Advocacy LLC. Clients will direct their own recovery and paperwork. Through the COPE TO HOPE session process.