Peer Wellness Client Application Form
Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
What is your sobriety date?
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a form of transportation?
*
I have my own car.
I take the bus.
I Uber everywhere.
I rely on family and friends.
I have no form of transportation.
Other
Are you currently employed?
*
Yes, Full-time employment.
Yes, Part-time employment.
No, I am not employed currently.
I am on disability and can not work.
Other
Do you have physical limitations? If yes, please explain.
*
Have you ever had a recovery coach before?
*
Yes
No
I'm not sure.
Other
What is something new you have wanted to try?
*
Are you willing to commit to meet with your coach in person once a week?
*
Yes
No
Other
Are you willing to commit to meet in a group setting with other members of the coaching group at least twice a month?
*
Yes
No
Other
Please list one personal reference. Include name and phone number.
*
Skillsets or Area of Interests
Comments
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