Apply for Recovery Coach Services at GAAP:
We are committed to providing compassionate and effective recovery coaching services to individuals seeking support in their journey towards lasting recovery. This application helps us understand your needs and determine how we can best assist you. Please answer the following questions thoughtfully and honestly. *Submitting this application, means that you certify that the information provided in this application is true and accurate to the best of your knowledge. You understand that this application does not guarantee acceptance into the recovery coaching program. You authorize GAAP Recovery to contact the individuals listed as emergency contacts and to verify any information provided.* Please email any questions to dawn@gaaprecovery.org
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What substances or behaviors have you struggled with? Please be specific (alcohol, opioids, gambling, eating disorders)
When did your substance use/problematic behavior begin?
Have you previously sought treatment for your substance use/behavior? If yes, please provide details (type of treatment, dates, location):
What is your current state of recovery? (ex: pre-contemplation, contemplation, preparation, action, maintenance)
Have you experienced any relapses? If yes, please describe briefly.
Do you have any co-occuring mental health diagnoses? (ex: depression, anxiety, PTSD)
Are you currently involved in any recovery support groups? (ex: AA, NA, SMART Recovery)
Are you currently taking any medications? If yes, please list.
What are your primary goals for recovery coaching? (ex: maintaining sobriety, developing coping skills, improving relationships, finding employment)
What specific areas of your life would you like to focus on with your recovery coach?
What are your expectations of a recovery coach?
What strengths do you possess that will contribute to your recovery?
What challenges do you anticipate facing in your recovery?
What does a successful recovery look like to you?
What are your preferred methods of communication? (ex: phone, text, email, in-person)
How often would you like to meet with your recovery coach?
Are you willing to commit to regular meetings and follow through on agreed-upon action steps?
What are your primary sources of support? (ex: family, friends, therapist, sponsor)
Do you have access to transportation?
Do you have stable housing?
Do you have access to healthcare?
Are you employed? If yes, please provide details.
Do you have financial concerns that may impact your ability to engage in recovery coaching?
Do you have any legal issues that may impact your recovery?
Is there anything else you would like to share with us about your situation?
How did you hear about our recovery coaching services?
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: