Recovery Coach Request Form
This form must be completed to the best of your ability.
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Gender Identity
*
Please Select
Male
Female
Race
*
Please Select
Hispanic or Latino
African American
Caucasian
Native American
Asian
Other Race
City and State
*
Street Address Line 2
City
State
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Tell us a short description for the reason for the request?
*
Drug of choice:
*
Opiates
Meth
Cocaine
Marijuana
Alcohol
Benzos
Other
Other Drug of Choice
*
Do you have a history of Overdoses
*
Yes
No
Do you have a disability/physical limitation that will prevent you from working?
*
Yes
No
Are you homeless?
*
Yes
No
Do you have insurance?
*
Yes
No
Do you have EBT?
*
Yes
No
Do you have driver's license?
*
Yes
No
Do you have identification card?
*
Yes
No
Do you have birth certificate?
*
Yes
No
What city and state were you born?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have social security card?
*
Yes
No
Are you taking any medication?
*
Yes
No
What medication are you prescribed?
*
Have you ever been tested for HIV or Hepatitis C?
*
Yes
No
Would you be interested in free testing?
*
Yes
No
Are you a veteran?
*
Yes
No
What branch did you serve?
*
Time frame of active duty?
*
Were you deployed in support of combat?
*
Yes
No
Do you need any of the following services
*
Detox treatment
Outpatient treatment
Inpatient treatment
Mental health services
Other
Other services requested not listed
*
IF APPROVED, YOU WILL BE ASSIGNED A RECOVERY COACH AND WILL BE REQUIRED TO ENGAGE WITH YOUR COACH. BY SIGNING YOU AGREE.
*
By acknowledging the above statement, please print name for signature above.
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