Recovery Coach Program Intake form
Weekly support and resources to other individuals in recovery, and creating peer-to-peer relationships that have the potential to change lives.
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Email *
Date *
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First and Last Name *
Phone number *
Address *
Drug of Choice *
What meetings or support groups do you like to attend, they can be in person or virtual?
Emergency Contact
Do you need help getting into treatment or finding a Chemical Dependency Assessment (Rule 25)? *
Are you employed? *
Are you in Drug Court? *
Are you on probation? *
If answered yes where and who is your probation officer.
Do you currently receive Recovery Support Services anywhere else? If so where and who is you Peer Support Specialist. *
Do you currently receive Mental Health Services? If so where? *
What is Sobriety birthday?
MM
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DD
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What kind of goals or barriers do you need help overcoming?
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