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MAT Testimonial Pre-Screener: MOUD/MAT Awareness and Equity Campaign
Background/Context:
- We are interested in hearing your story, in your own language and style, about using medications for opioid-use disorder (MOUD) as part of your recovery journey.
- We are asking you to either: (1) self-record a short (3-4 minute) video telling your story; or (2) participate in a recorded, online (Zoom) small-group discussion with others who are using various forms of MOUD.
- Through these stories, we hope to help BIPOC families and individuals in Allegheny County understand the various MOUD/MAT options available to them, along with the recovery supports that are essential to the overall process.
For More Information Visit: MOUD MEE Productions
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Are you an Allegheny County resident?

YesNo
Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your race/ethnicity?

African-American/BlackLatino/LatinxBiracialOther
What if your gender identity?

MaleFemaleOther
Are you a “returning citizen” or have you been previously incarcerated in AlleghenyCounty?

YesNo
Have you received treatment for a substance use disorder that included medication-assisted treatment (MAT)?

YesNo
Which of these best describes your use of medication-assisted treatment (MAT) or medication for opioid use disorder (MOUD) (Check only one):

Currently Using MATUsed MAT within the past two yearsSuccessfully Used MAT within the past five (5) years and have fully withdrawn.
Which medication(s) are you using or have recently used (within the past 2 years) for treatment of an opioid use disorder? (Choose all that apply)

Buprenorphine/Suboxone/ZubsolvSublocade/Brixadi (Long-acting injectable Buprenorphine)Vivitrol (Long-acting injectable Naltrexone)MethadoneOther
For how long have you used or did you use medication-assisted treatment (MAT)?
From what provider/prescriber did you get your medication-assisted treatment (MAT)?
Provider Name and/or Agency
While you were using MAT (currently or previously), do you or did you feel like you were made aware of the various recovery supports (i.e., support groups, counseling, therapy) that should go along with the medications?

YesNo
How often were they offered (once, twice, often, repeated) and how were you onboarded into recovery supports?
If selected, how would you prefer to share your MAT story and experiences, and be video recorded?

Record a self-video on my ownParticipate in a recorded Small-Group discussion on Zoom (Video)
Should be Empty:

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