Kingdom Recovery Center: Recovery Coach Request Form 
Please complete this referral form to get in contact with a recovery coach for peer support.
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Today's Date *
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Email 
First Name  *
Last Name  *
Date of Birth *
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Phone Number 

Please include area code
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Is it ok to leave a Voicemail? *
Can we text you at the phone number you provided? *
What is your address or the address of where you have been staying at?
(If you are unhoused please type "Unhoused" and if you are staying in a hotel please list the name of the establishment in addition to the address.)
What gender do you identify as?
Clear selection
What are your pronouns?
Clear selection
What is your insurance type?

*Insurance is not required to receive services*

(Example: Blue Cross Blue Shield, Medicaid, None)
Why are you reaching out to us today?

Please provide as much information as you are comfortable with.

(Examples: "I am struggling with alcohol use and I need help getting connected to treatment"

"I am in recovery and looking for a recovery coach to support me with maintaining my sobriety")
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We’d like to match you with a recovery coach who best fits your needs. Please select any categories that describe your situation:  
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Is there any additional information that you'd like the coach that'll be reaching out to you to know?
Submit
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