Participation form - Recovery story

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An initiative to help other patients (participant) and their families by sharing a recovery story and inspire them to fight addiction and mental health related issues. There are two section of this form:-

Section 1 - For the person submitting the story
Section 2 - For the recovery story and the participant

*DISCLAIMER- WE DO NOT EXPECT DETAILS ABOUT THE PATIENT TO ENSURE ANONYMITY. HOWEVER, ITS THEIR CHOICE TO ANSWER THE RELATED QUESTIONS.

Name and details of the person submitting the form? *

Do you want yourself to share this anonymously? *

Yes

If you are center owner/therapist or a counselor, please give a detailed background about your offerings and setup. We would love to promote you so that more people can reach out to you for help. *

Relation to the participant *

Centre owner/ Counselor/ Therapist

Friend

Relative/Family

Self

Others

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