Sisters of Sobriety Community Outreach for Success Application
This application is for all community members - women, men, and families - seeking support through the the Sisters of Sobriety Community Outreach for Success Program. Individuals do not need to be fully abstinent to receive outreach support. Services are available for those actively working toward recovery, stability, and improved life circumstances, as well as for families affected by a loved one's substance use or life challenges. Services may include peer recovery support, recourse connection, goal planning, advocacy, and community based guidance. Connections can take place in person, by phone, or through ZOOM. We will meet you where your at.
PERSONAL INFORMATION
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
City and County of residence
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Preferred contact method
*
Phone call
Text message
Email
ZOOM
In person
Current living situation
*
Stable housing
Staying with friends/family
Shelter or sober living
Homeless
Other
Who is this outreach support for?
*
Myself
My child
My partner/spouse
Another family member
Someone I support in the community
Current recovery or substance use status
Actively using but want help
Early recovery (0-90 days)
Stable recovery (90+ days)
Supporting a loved one
Prefer not to answer
What kind of support are you looking or?
*
Peer Recovery Support, (recovery coach services)
Resource connections
Goal planning/life stability
Family support
Advocacy or system navigation
Not sure yet
What is the biggest challenge you are facing right now?
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Is it safe for us to contact you at the phone/email you provided?
*
Yes
No
If not safe, what is the safest way to reach you?
How soon do you ned support?
*
As soon as possible
Within a few days
Within a week
Just exploring resources
Is there anything else you would like us to know or any specific help you are seeking?
Consent for Outreach Contact
*
Choice 1: I understand this is peer recovery outreach (not treatment or emergency care) and give permission for Sisters of Sobriety to contact me.
Choice 2: I do not consent.
Submit
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