Online Peer-to-Peer Sobriety Community Sign-Up Form

Online Peer-to-Peer Sobriety Community Sign-Up Form

Welcome! We are glad you are here. Please fill out this form to join our supportive community. Please note, if you are filling this form out for another individual, please complete it with all of their information.
Your Name*

First NameLast Name
Preferred Name/Nickname*
Email*
example@example.com
Preferred Phone Number*
How did you hear about Recovery Unbroken?*

TiktokFacebookInstagramYouTubeGoogle SearchFriendTreatment CenterOther
If you selected Treatment Center or Other, please provide your answer here.
Sobriety Information
Date of Sobriety*

DayMonthYear
Primary Substance(s) of Concern*
Previous Recovery Programs or Support Groups (if any)
Goals and Interests
What are your primary goals for joining this community? (Select all that apply)*

Finding a support networkSharing experiencesLearning new coping strategiesOffering support to othersOther
If you selected "other" above, please describe
Privacy and Participation
How would you like to participate in the community? (Select all that apply)*

Actively participating in discussionsListening and learning from othersSharing my storyVolunteering to help organize events or activitiesOther
If you selected "other" above, please describe
Preferred Method of Communication*

EmailPhoneOnline forum/chatVideo meetingsOther
If you selected "other" above, please describe
Additional Information
Do you have any specific needs or accommodations to help you participate fully in this community?*
Is there anything else you would like us to know about you?
Agreement
I agree to respect the privacy and confidentiality of all members in this community.*

YesNo
I agree to abide by the community guidelines and participate in a positive and supportive manner.*

YesNo
Once payment is received you will be emailed a link (within 24 hours) for the Recovery Unbroken discord server. Although this one time link never expires, it should be activated right away in order to participate in the Recovery Unbroken Community and see Zoom information.*

I understand

Sobriety Support Group Membership

Monthly SubscriptionReceive compassionate, continuous support on your healing journey.

$48.00 for each month

6 Month SubscriptionReceive compassionate, continuous support on your sobriety journey.

$240.00 for each six months

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Thank you for taking the time to complete this form. We look forward to supporting each other on this journey to sobriety. Welcome to the community!
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Online Peer-to-Peer Sobriety Community Sign-Up Form

Sobriety Information

Goals and Interests

Privacy and Participation

Additional Information

Agreement