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*
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
Finding a support networkSharing experiencesLearning new coping strategiesOffering support to othersOther
If you selected "other" above, please describe
Privacy and Participation
Actively participating in discussionsListening and learning from othersSharing my storyVolunteering to help organize events or activitiesOther
If you selected "other" above, please describe
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
YesNo
YesNo
I understand

Sobriety Support Group Membership

Monthly Subscription

Receive compassionate, continuous support on your healing journey.

$48.00 for each month

6 Month Subscription

Receive compassionate, continuous support on your sobriety journey.

$240.00 for each six months

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:

Sobriety Information