True Colors Referral Form
Our PRIME+ Recovery Mentors provide free, confidential peer support to adults ages 18 and older in the LGBTQ+ community and allies who live in Multnomah County. PRIME+ particularly focuses on supporting people who currently use or have a history of using illicit or non-prescribed drugs and who may be at risk for overdose, infection, or other health concerns related to substance use. Mentors provide individualized support and can work with people at any stage—including active use, reducing use, considering recovery, receiving treatment, or maintaining recovery
True Colors Service Overview
In addition to PRIME+ Recovery Mentoring, True Colors offers drop-in recovery support at our location on MLK Blvd in Portland. These services include recovery meetings, recovery-focused events, skill-building groups, and other community-based support. Drop-in services are open to anyone seeking recovery support and do not require enrollment in PRIME+ Recovery Mentoring.
Individuals Name
*
First Name
Last Name
Gender Identity
Preferred Pronoun
Individuals Age
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
PRIME+ Recovery Mentor Assessment
The following questions will help us determine whether PRIME+ Recovery Mentoring is a good fit for your needs. Please select all responses that apply to you.
Which of the following best describes what you are looking for support with? Select all that apply.
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I am currently using substances and would like support reducing risks related to my use.
I have recently reduced or stopped using substances and would like recovery support.
I am currently in treatment or would like help connecting to treatment.
I am in recovery and would like ongoing peer support.
I would like help connecting to healthcare or other services related to my substance use.
I am unsure what kind of support I need and would like to talk with a Recovery Mentor
None of the Above
Other
If you answered yes to any of the previous statements, please continue.
Do you live in Multnomah County ( only servicing clients within Multnomah County)
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Yes
No
What type of services would you like to participate in at True Colors?
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Recovery Mentoring (someone in recovery who helps you find/sustain recovery)
Mutual -Aid Recovery Support (12 step and other types of recovery meetings)
I am wanting more information
Have you experienced or been concerned about any of the following related to substance use? Select all that apply
*
Overdose or risk of overdose
Fentanyl exposure or concern about fentanyl
Injection drug use
Hepatitis C, HIV, STIs, or other infection concerns
Wounds or other health concerns related to substance use
Difficulty accessing healthcare or substance use treatment
Prefer not to answer
Which substances do you currently use or have you used in the past? Select all that apply.
*
Fentanyl, heroin, or other opioids
Methamphetamine/Cocaine/crack
Other stimulants
Non-prescribed prescription medications
Alcohol
Marijuana/cannabis
None of the above
What, if any, other services do you think you need?
*
Detox or Residential Treatment
Mental Health Treatment
Housing
Employment
Education
Primary Care Medical care
Hep C/ STD Testing
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Agency (if applicable)
Anything else we should know?
*
Submit
Should be Empty: