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Freedom Recovery Groups
This form allows me to collect some valuable information that assists me in facilitating groups. Any information is both HIPPA protected, in addition to being treated with confidentiality outlined in 42 CFR. I appreciate your attention to detailed responses, as well as your honesty. I look forward to seeing you in group!
First and Last Name
Date of Birth
What types of recovery programs, if any, have you previously been involved in?
Addiction Counseling (one on one)
Medication Assisted Treatment (MAT- Methadone, Suboxone, Vivitrol or Antibuse)
Short-Term Residential Treatment (21-60 days)
Long-Term Residential Treatment (90 days-1 year)
Sober Living or Recovery Home
At this moment, how motivated do you feel towards a life of clarity, without substances?
Not at all motivated- would like to continue using
Very motivated- would enter treatment tomorrow if necessary
What barriers do you anticipate to your recovery?
What do you hope to receive from attending groups?
Can you commit to attending every group for the 13 week cycle?
How did you hear about Freedom Recovery Groups?
What else would you like me to know about you?
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