Homebound Service Request
OUR PRIMARY PURPOSE IS TO HELP ANOTHER ALCOHOLIC TO ACHIEVE SOBRIETY

Thank you for requesting the Homebound Service for the Tri-Valley Area. The following questionnaire will be used to help us to align you with the Homebound Service you are requesting along with volunteers in your area.  
If you have questions or concerns, please contact us at homebound.chair@gmail.com.
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First Name *
Last Initial *
Last initial - No last names shall be used.
Phone Number
Email Address
Are you over the age of 18? (Must be over the age of 18 or have an adult present to utilize this service) *
Do you relate as an Alcoholic?
This service is provided by Alcoholics Anonymous and follows the 12 steps and 12 traditions as outlined in the Big Book of Alcoholics Anonymous.
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Gender
What type of meeting would you like? *
Required
Day(s) of the week that you are available for a meeting *
Required
Time(s) you are available *
What city do you live in?
Min sobriety length that can attend                                                                                                                                                                             *
Min sobriety length you would prefer the volunteers to have when they come to your location.
What type of service do you want from Homebound?
Maximum # of people that can attend the meeting
Do you have pets? *
Please check all that apply
Required
Do you have allergies? *
Please check all that apply
Required
Have you Been Covid Vaccinated? *
Are you contagious?
Additional Comments - Anything else we should know?
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