The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

New Client Contact Form

Please provide contact information for your SOR client. Note: You will need to create a GPRA client ID that will be used in this form as well as in the GPRA Intake Survey.

Thank you!

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Client Contact Form

I am submitting a GPRA Client Contact Form for a:

New SOR client (has not received SOR-funded services).

Client transitioning from the previous SOR II grant.

Client transitioning from other funding sources (i.e. Medicaid or private insurance).

Client that has already completed a GPRA intake survey and has updated client contact information.

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SOR Provider Information

Which SOR-funded services is this client engaged in:

Medications for Opioid Use Disorder for the Under/Uninsured

Mobile Health Unit Services

Peer Services through Recovery Community Organizations

Mobile Medications for Opioid Use Disorder to the Under/Uninsured

Contingency Management

Recovery Residences 1st Month Rent

Residential Treatment

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Select your provider name:

Your first name:

Your last name:

Your email address:

Your phone number:

Client Contact Information

You will enter your site ID as the first six digits of the GPRA Client ID.

Your site ID is:

View equation

You will enter your site ID as the first six digits of the GPRA Client ID.

Your site ID is listed in the table below:

Provider Name	Site ID
Front Range Clinic (Region 1)	MU0001
Jefferson Center for Mental Health (Region 2)	MU0002
Front Range Clinic (Region 3)	MU0003
Front Range Clinic (Region 4a)	MU0004
San Luis Valley Behavioral Health Group (Region 4b)	MU0005
Front Range Clinic (Region 6)	MU0006
ARTS Mobile OTP Unit	MU0007
Denver Health Mobile OTP Unit	MU0008

For future reference, you may find your site ID on the Client ID Convention guide at https://www.sorcolorado.org/sor-gpra/resources.

GPRA Client ID:

Client First Name:

Client Last Name:

Date of GPRA Intake:

M-D-Y

Select how your client was referred to SOR services:

If other, please list who referred the client to the SOR services:

How did your client travel to today's appointment?

If other, please list the client's mode of transportation to today's appointment:

Please note any accommodations that may support the client's ability to participate in the GPRA follow-up survey:

Does ______ have an email address that we may contact them at?

Yes

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Email Address:

Does ______ have an existing phone number that we may contact them at? If no, we will contact you for updated contact information when the client is due for follow-up.

Yes

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Primary Phone Number:

Yes

Okay to Call

Okay to Text

Okay to Leave Voicemail

Secondary Phone Number:

Yes

Okay to Call

Okay to Text

Okay to Leave Voicemail

Does ______ currently have a mailing address?

Yes

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Address

City

State

Zip Code

Missing Client Contact Information

Warning:
You did not provide a phone number or email address for ______. This information is essential for The Evaluation Center to contact for their required GPRA Follow-up Survey. We will be contacting you when it is time to complete the GPRA Follow-up for this client so that we may coordinate a phone call with them.

If you did not submit a phone number or email address in error, please enter the appropriate contact information above and proceed.

______'s Back-up Contact Information

Back-up Contact One

If ______ cannot provide any back-contacts, enter your name below and select "provider."

Name

Relationship to ______

If you selected "other," please list the relationship to ______.

Mobile Phone Number

Home Phone Number

Back-up Contact Two

Name

Relationship to ______

If you selected "other," please list the relationship to ______.

Mobile Phone Number

Home Phone Number

Back-up Contact Three

Name

Relationship to ______

If you selected "other," please list the relationship to ______

Mobile Phone Number

Home Phone Number

Submit the Client Contact Form Below

Thank you for entering ______ ______'s contact information. Follow the steps below to proceed to complete the data entry:

Copy the following GPRA Client ID: ______. You will paste this GPRA Client ID into the GPRA Intake Survey.
Select "submit" below.
Navigate back to the SORColorado.org website to complete Step Three - Administering the GPRA Intake Survey.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.