Sober Strong Referral Form
A specialized program at the Eau Claire YMCA for women in early recovery from substance use disorder. Sober Strong combines group exercise with supportive services to create connection and belonging while reducing post-acute withdrawal symptoms in early recovery.
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Referral Agency
*
Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Phone Number
*
Please enter a valid phone number.
Agency Contact Name
*
First Name
Last Name
Please briefly state why you believe this individual would benefit from Sober Strong.
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Do you feel this person has any limitations regarding aerobic exercise?
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Sober Strong has the potential to trigger trauma memories. Do you feel this individual has appropriate support outside of Sober Strong if the need arises?
*
Anything else you would like to add?
Submit
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