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Welcome House Information Questionnaire
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Name (First and Last name or Last Initial)
Your answer
Have you lived at Welcome House?
Yes, I graduated Welcome House
Yes, but I did not graduate Welcome House
No I never lived at the Welcome House
Clear selection
What is your phone number? No dashes or spaces, please. (Your phone number will not be used without your consent)
Your answer
What is your e-mail address? (Your e-mail will not be used with out your consent)
Your answer
Would you like like to get occasional contact regarding the Welcome House, Alumni After Care services, and special events?
Yes
No
Clear selection
What is your preferred method of contact?
Phone Call
Text Message
Email
Facebook Messenger
Do Not Contact
Would you be interested in getting involved with the active residents at Welcome House?
Yes
No
Maybe
Clear selection
Check what you are interested in
Recovery Coaching or "Lay Counseling"
Teaching a Welcome House University Class
Chairing or Co-chairing an in house AA or NA meeting
Other:
Are you in recovery from alcohol and drug use? If "Yes" please complete the rest of the survey. If "No" you just click submit at the end of the survey.
Yes
No
Clear selection
What is your recovery date?
MM
/
DD
/
YYYY
Are you in AA or NA?
Alcoholics Anonymous
Narcotics Anonymous
Both
Choose Not to Disclose
Other:
Clear selection
Would you, please, disclose what group you attend the most? Please feel free to include include city and/or state.
Your answer
Submit
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