ATWW Request for Peer Recovery Specialist

Request for Peer Recovery Support
Name*

First NameLast Name
Nickname
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Demographics
What is your ethnicity?
What is your date of birth?

MonthDayYear
Date
Current Recovery Programming
Are you currently receiving recovery related service?
What type of recovery services are you CURRENTLY receiving

In Sober LivingIOP - Intensive outpatientResidential TreatmentDetox
Name of your treatment / recovery service provider
Insurance Information
Do you have Health Insurance? *
Insurance Provider
Policy Number, Medicaid Number or Social Security Number
What services are you most interested in?

Recovery navigationResource support (state benefits, scholarship assistance, recovery programming)Career DevelopmentGeneral Peer Support
What Peer services settings are you most interested in attending?

Peer GroupsPeer Events1:1 Peer ServicesPeer Programming - Recovery workouts, book club, hikes, and more
How many hours per week would you like to work with a Peer Specialists?
Next Steps - Upon receipt of your contact request you will receive a call from our intake coordinator within 24-48 hours. If you'd like to speak with someone now, please call our mainline at: 720-706-9518
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Request for Peer Recovery Support