Welcome House Information Questionnaire
Name (First and Last name or Last Initial)
Have you lived at Welcome House?
Yes, I graduated Welcome House
Yes, but I did not graduate Welcome House
No I never lived at the Welcome House
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?
What is your preferred method of contact?
Do Not Contact
Would you be interested in getting involved with the active residents at Welcome House?
Check what you are interested in
Recovery Coaching or "Lay Counseling"
Teaching a Welcome House University Class
Chairing or Co-chairing an in house AA or NA meeting
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.
What is your recovery date?
Are you in AA or NA?
Choose Not to Disclose
Would you, please, disclose what group you attend the most? Please feel free to include include city and/or state.
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This form was created inside of Welcome House, Inc..