Welcome House Information Questionnaire
Name (First and Last name or Last Initial)
Have you lived at Welcome House?
Clear selection
What is your phone number? No dashes or spaces, please. (Your phone number will not be used without your consent)
What is your e-mail address? (Your e-mail will not be used with out your consent)
Would you like like to get occasional contact regarding the Welcome House, Alumni After Care services, and special events?
Clear selection
What is your preferred method of contact?
Would you be interested in getting involved with the active residents at Welcome House?
Clear selection
Check what you are interested in
Are you in recovery from alcohol and drug use? If "Yes" please complete the rest of the survey. If "No" you just click submit at the end of the survey.
Clear selection
What is your recovery date?
MM
/
DD
/
YYYY
Are you in AA or NA?
Clear selection
Would you, please, disclose what group you attend the most? Please feel free to include include city and/or state.
Submit
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