• Michigan Recovery Movement • 28009 John R Rd, Suite A, Madison Heights, MI 48071

  • Michigan Recovery Movement • 28009 John R Rd, Suite A, Madison Heights, MI 48071

  • PEER RECOVERY COACHING INTAKE

    PARTICIPANT INTAKE FORM

  • You are welcome. You are not alone. We recover together.

  • This form helps us get to know you and match you with the Peer Recovery Coach best suited to support your goals. There are no wrong answers. Your responses are confidential and used only for coaching and program purposes.

  • 1. CONTACT INFORMATION

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • County of Residence*
  • Michigan Recovery Movement can contact me by:*
  • May we leave a voicemail identifying Michigan Recovery Movement?*
  • Best Time to Reach You*
  • Format: (000) 000-0000.
  • How did you hear about MRM?*

  • 2. RECOVERY BACKGROUND

  • What are you seeking recovery support for? (Check all that apply)*
  • If gambling: what forms have been most problematic? (Check all that apply)*
  • Would you like information, training, or access to naloxone (Narcan)?*
  • What recovery pathway(s) have you tried or are interested in? (Check all that apply)*

  • Michigan Recovery Movement • 28009 John R Rd, Suite A, Madison Heights, MI 48071 • Page 1 of 3

  • Are you currently working with a therapist, doctor, counselor, or case manager?*

  • 3. CURRENT SITUATION

  • What is your current living situation?*
  • Which of the following currently apply to you? Select all that apply.*
  • Do you have reliable transportation?*
  • Are you currently involved with the court system, probation, or parole?*
  • Are you experiencing financial hardship or debt related to gambling or substance use? (optional)*
  • Do you have any immediate needs? (Check all that apply)*

  • 4. GOALS & MOTIVATION

  • 5. SUPPORT SYSTEM

  • 6. COACH MATCHING

  • Do you have a preference for your coach's gender?*
  • Is it important that your coach shares similar lived experience? (substance use, gambling, background, faith, culture)*
  • What communication style works best for you in a coach?*
  • Preferred meeting format and availability:*

  • 7. SAFETY & WELLNESS

  • Michigan Recovery Movement-Participant Intake •Page 3 of 3

  • Should be Empty: