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Participant Form
Recovery Support Information for Participants
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
STREET ADDRESS/PO BOX
*
Your answer
CITY/TOWN
*
Your answer
ZIP CODE
*
Your answer
Phone number XXXXXXXXXX (No dashes or spaces)
*
Your answer
E-mail
*
Your answer
Best Way to Contact You?
Email
Phone
Mail
Clear selection
Age
*
Under 18
18-20
21-24
25-44
45-64
65+
Gender
*
Male
Female
Transmale
Transfemale
Non-Binary
Prefer not to respond
Other:
Race
*
African American
American Indian/Alaskan
Arab-American/Chaldean
Asian
Hispanic
Multi-Racial
White
Other:
Current Situation
*
Need Recovery Support
Treatment
Probation
Jail/Prison Referral
Sober Support Unit
Prefer Not to Say
Other:
Required
Do you believe you have a substance use disorder?
*
Yes
No
Not sure
How important is sobriety to me? 1 = Not important; 10 = Very important
*
1
2
3
4
5
6
7
8
9
10
How confident am I that I can maintain sobriety? 1 = Not confident; 10 = Very confident
*
1
2
3
4
5
6
7
8
9
10
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