Recovery Coach Request Form
This form must be completed to the best of your ability.
**IF YOU SIGNED UP FOR A SOBER LIVING SCHOLARSHIP, YOU ARE ALREADY ASSIGNED A RECOVERY COACH AND DO NOT NEED TO FILL OUT THIS FORM.**
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Gender Identity
*
Please Select
Male
Female
Race
*
Please Select
Hispanic or Latino
African American
Caucasian
Native American
Asian
Other Race
City and State
*
Street Address Line 2
City
State
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Tell us a short description for the reason for the request?
*
Drug of choice:
*
Opiates
Meth
Cocaine
Marijuana
Alcohol
Benzos
Other
Other Drug of Choice
*
Do you have a history of Overdoses
*
Yes
No
Do you have a disability/physical limitation that will prevent you from working?
*
Yes
No
Are you homeless?
*
Yes
No
Do you have insurance?
*
Yes
No
Do you have EBT?
*
Yes
No
Do you have driver's license?
*
Yes
No
Do you have identification card?
*
Yes
No
Do you have birth certificate?
*
Yes
No
What city and state were you born?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have social security card?
*
Yes
No
Are you taking any medication?
*
Yes
No
What medication are you prescribed?
*
Have you ever been tested for HIV or Hepatitis C?
*
Yes
No
Would you be interested in free testing?
*
Yes
No
Are you a veteran?
*
Yes
No
What branch did you serve?
*
Time frame of active duty?
*
Were you deployed in support of combat?
*
Yes
No
Do you need any of the following services
*
Detox treatment
Outpatient treatment
Inpatient treatment
Mental health services
Other
Other services requested not listed
*
Where were you referred to us by?
*
Please Select
Drug Court
Probation Officer
Pasco County Detention Center
Pinellas County Jail
Florida Women's Reception Center
Taylor Correctional institution
Hamilton Correctional Institution
Volusia County Jail
Hernando County Detention Center
Putnam County Jail
Lancaster Correctional Institution
Clean Recovery Center
Rockland treatment center
CRC (Community Recovery Center)
Banyan Treatment Center
Turning Point of Tampa
ACTS Keystone
River Oaks
Baycare ISU
White Sands
Catchers Mitt
Cove Behavioral Health
Mandala Healing Center
Outfield
Spring Garden
Women at the Well
Ruth House
Boaz House
Da Vinci Recovery Homes
Ace Opportunities
Harmony House
ARC Pasco
ARC Pinellas
Oxford House Peace River
Oxford House Land O Lakes
Oxford House Gulf Oasis
Oxford House Grace Valley
Steps To Recovery
Real Recovery New Port Richey
Real Recovery Brandon
Real Recovery Bradenton
Real Recovery Clearwater
Real Recovery North Tampa
Real Recovery St Petersburg
Other
(Please look through the choices to answer correctly)
Other Referred
*
IF APPROVED, YOU WILL BE ASSIGNED A RECOVERY COACH AND WILL BE REQUIRED TO ENGAGE WITH YOUR COACH. BY SIGNING YOU AGREE.
*
By acknowledging the above statement, please print name for signature above.
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