Participant Form
Recovery Support Information for Participants
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First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
STREET ADDRESS/PO BOX *
CITY/TOWN *
ZIP CODE *
Phone number  XXXXXXXXXX (No dashes or spaces) *
E-mail *
Best Way to Contact You?
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Age *
Gender *
Race *
Current Situation *
Required
Do you believe you have a substance use disorder?
 *
How important is sobriety to me?  1 = Not important; 10 = Very important
 *
How confident am I that I can maintain sobriety?  1 = Not confident; 10 = Very confident
 *
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