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Recovery Coach Program Intake form
On going support and resources to individuals in recovery.
* Indicates required question
Email
*
Your email
Full Name (First, Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Address
*
Your answer
Are you a veteran?
yes
No
Clear selection
Drug of Choice
*
Meth
Alcohol
Heroin
Prescription Medication Misuse
Other:
Required
Gender
male
female
transgender
gender neutral
Two- Spirit
Other:
Clear selection
Race
White
African American
American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander.
Asian
Other:
Clear selection
What, if any, support group meetings to you attend?
AA
NA
Welbriety
Faith Based
Other:
Clear selection
Emergency Contact
Your answer
Do you need help getting into treatment or finding a Chemical Dependency Assessment (Rule 25)?
*
Yes
No
Maybe
Are you employed?
*
Yes
NO
Other:
Are you in Drug Court?
*
Yes
No
Are you on probation?
*
Yes
No
Other:
If answered yes where and who is your probation officer.
Your answer
Do you currently receive Recovery Support Services anywhere else? If so where and who is you Peer Support Specialist.
*
Your answer
Do you currently receive Mental Health Services? If so where?
*
Your answer
What is your Sobriety birthday?
MM
/
DD
/
YYYY
What kind of goals or barriers do you need help overcoming?
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
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