Trip Approval Request Form
Name
First Name
Last Name
Email
example@example.com
General Trip Details
Trip Destination
*
Location Information
In-State
Out-of-State
Departure Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Return Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location Details
Who will you be staying with?
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Purpose of Trip
Trip Objective
What do you plan to do for your recovery while on your trip?
What is your Relapse Prevention Plan? (Include possible triggering situations that may happen on your trip.)
Transportation
Method of Transport
Private Vehicle
Bus Company
Airline Carrier
Other
Make and Model of Vehicle
Plate #
Name of Carrier
Flight #
Bus Company
Bus #
Agreements
You are required to check in daily with staff while are your trip. Do you agree to this?
Yes
No
Do you give permission for us to contact whomever you are staying with?
Yes
No
Additional Comments
Save
Submit
Should be Empty: