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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!
Email address *
First and Last Name *
Your answer
Phone Number *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
What types of recovery programs, if any, have you previously been involved in? *
Required
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? *
Your answer
What do you hope to receive from attending groups? *
Your answer
Can you commit to attending every group for the 13 week cycle? *
How did you hear about Freedom Recovery Groups? *
Your answer
What else would you like me to know about you?
Your answer
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