Recovery Coach Request
Personal Information
Birthdate *
Month
Day
Year
Gender Identity *
Male
Female
Other
Prefer not to say
Race *
Hispanic or Latino
African American
Caucasian
Native American
Asian
Other Race
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Health & Immediate Needs
Drug of Choice *
Opiates
Meth
Cocaine
Marijuana
Alcohol
Benzos
Other
Recovery Date (Clean/Sober Date)
Month
Day
Year
History of Overdose? *
Yes
No
Disability Preventing Work? *
Yes
No
Are You Homeless? *
Yes
No
Insurance Type *
Medicaid
Medicare
Private
None
Other
Do You Have EBT? *
Yes
No
Driver’s License? *
Yes
No
Identification Card? *
Yes
No
Birth Certificate? *
Yes
No
Social Security Card? *
Yes
No
Tested for HIV or Hep C? *
Yes
No
Interested in Free Testing? *
Yes
No
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Veteran, Services & Referral
Are You a Veteran? *
Yes
No
Deployed in Combat? *
Yes
No
Service Needed *
Detox treatment
Outpatient treatment
Inpatient treatment
Mental health services
Other
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Consent & Signature
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