CCAR Recovery Coach Academy Application
CCAR Recovery Coach Academy Training Hosted by The Gathering Place and Facilitated by Stephanie Short. Funded by the Advancing a Healthier Wisconsin Endowment.
Basic Information
1. First Name
*
2. Last Name
*
3. Email Address
*
example@example.com
4. Phone Number
*
Format: (000) 000-0000.
5. County or Tribe
*
6. Current Employment/Role
*
Education & Eligibility
7. What is the highest level of education you have completed?
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High School Diploma
GED
HSED
Other
8. Are you at least 18 years old?
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Yes
No
Recovery Experience
9. Which best describes your connection to recovery?
*
I am a person in recovery
I have a loved one who is struggling with substance use disorder or is in recovery
I am an ally/supporter of recovery
Mental Health/SUD Professional
Other
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10. If you are a person in recovery, how long have you been on your recovery journey?
*
Less than 6 months
6 months–1 year
1–2 years
2–5 years
Over 5 years
Not applicable
Interest in Recovery Coaching
11. Why are you interested in becoming a Recovery Coach?
*
12. What experience do you have with recovery, peer support, substance use services, or helping others? (This can include personal, professional, volunteer, or community experience.)
*
13. What do you currently understand about the role of a Recovery Coach?
*
14. What strengths do you have that would help you be an effective Recovery Coach?
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15. What do you hope to gain from this training?
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Training Commitment
16. Are you able to attend all required training sessions? Training Dates 10/10, 10/11, 10/17, 10/18, & 10/25.
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Yes
No
I'm not sure and would like to discuss
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17. Is there anything that could make it difficult for you to attend or complete the training?
*
18. What support, if any, would help you successfully complete the training?
*
Learning Environment
19. Are you willing to participate respectfully and help create a safe and supportive learning environment?
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Yes
No
20. Is there anything that could affect your ability to participate fully in the training or learning environment that you would like us to know?
*
Final Question
21. Is there anything else you would like us to know about you or why you are interested in Recovery Coaching?
Submit
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