CARES Warm Line Assertive Telephone Outreach (ATO) Program

Date*

Today's Date

First name *

Last Initial *

Preferred name:

City*

State*

Zip*

Cell*

Contact Information

Birth Date*

Date

Gender

How did you hear about the program?

What is your current living situation?*

Halfway HouseIndependentSober LivingOther

Seeking support for?

Substance UseMental HealthOther

What language do you prefer to speak?*

EnglishSpanishOther

Are you in medication assisted treatment (MAT)?*

YESNO

If Yes- What is the name of your provider/facility

Telephone Recovery Support calls and texts are made between 9 am and 11 pm Eastern time, 7 days a week. Please indicate when you would like us to reach out by selecting a day and time slot options below.

What day should we contact you? (When scheduling your initial check-in, please allow at least 48 hours/2 days from the day you sign up)*

Date

Between which hours?*

How would prefer to be contacted?

TelephoneText

Is it OK to leave a message?

YESNO

By clicking submit you are agreeing to the following:

I grant permission for a Peer Recovery Coach from the GCSA CARES Warm Line to call me at the indicated telephone number to support me in my recovery. I will receive 6 calls related to this enrollment. I understand I will need to submit a new form if I would like to continue services and receive an additional 6 calls from a CARES Warm Line Peer Recovery Coach.
Each time the Peer Recovery Coach calls or texts, he/she will be asking me how my recovery is progressing and if I am in need of additional support (i.e., meetings in area, recovery community centers, safe/sober housing, social events, other resources).
At any time I may decide not to take part in this service, I will call the GCSA CARES Warm Line at 1-844-326-5400 or tell the Peer Recovery Coach when he/she calls or texts.

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Connection is the Opposite of Addiction