Standard Application for Recovery Coach Training

Standard Application for Recovery Coach Training
Date

MonthDayYear
Choose date for class.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please answer the following questions:
1. Do you have a minimum education of a GED or High School Diploma?

NoYes
2. Are you a Texas Resident?

NoYes
3. Are you over the age of 18?

NoYes
4. Are you a Veteran?

NoYes
5. Please list all languages that you speak
6. Are you (choose all that apply)

In recoveryNot in recovery, but a recovery allyLicensed Addiction ProfessionalFamily/friend of someone in recoveryOther
7. If you are in recovery, how long have you been in recovery?
8. Tell us briefly about your recovery story (limit 150 words)
9. Are you currently volunteering or working at an organization that provides Recovery Support Services?

NoYes
a. If not, how do you plan on using your Recovery Coach training?
b. If so, what Organization are you working/volunteering at? Please provide Organization name, Supervisor name and phone #
10. What is your purpose for taking this training?

a. I am going to pursue/am pursuing the certification credentialsb. I am going to pursue /am pursuing the designee credential (if residing in Texas)c. I do not plan on pursuing a recovery coach credentialsd. I am not familiar with the certification credentil or credentialing process
If you selected a or b please fill out the following information Please provide Organization name, Supervisor name and phone #
11. In addition to your experience, what other ways can people experience/find recovery?
12. Is there anything you wish to share, such as experience of trauma or life disruptions Please do so at your comfort? Please indicate if you do not wish to share/have nothing to share:
By signing and submitting this application I acknowledge that my role as a Recovery Coach is and must be completely separate from any other role, including that of clinician or sponsor. I also acknowledge that recovery is self-guided and that my role as Recovery Coach may include assisting others on their chosen path, whether that includes abstinence based, medication assisted, harm reduction, or any other path to recovery.

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Date

MonthDayYear
ADDITONAL IMPORTANT INFORMATION:

Your application will be reviewed and if accepted you will be notified and will be sent some pre homework that will need to be submitted before 1st day of class.

Once you are accepted you will be sent link for payment.

If none of the above is complete you will not receive your certificate of completion until it is completed.

Any quuestions please contact:

Jose Martinez- jmartinez@sacada.org

Elizabeth Garcia 210-517-8245 egarcia@sacada.org

Donny Vanblaricum 210-787-0019 dvanblaricum@sacada.org
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Standard Application for Recovery Coach Training

Please answer the following questions: