NMSAS Peer Recovery Coach Application

• 
  Application Date
  

• First Name

  Middle Name

  Last Name

  Date of Birth

• Street Address

  City

  Zip Code

• Phone Number

  Email Address

  County Choose Alcona Alpena Antrim Benzie Charlevoix Cheboygan Crawford Emmet Grand Traverse Iosco Kalkaska Leelanau Manistee Missaukee Montmorency Ogemaw Oscoda Otsego Presque Isle Roscommon Wexford Other

• Gender: Male Female

  Sobriety Date

• Person that referred you to NMSAS
  
• Emergency Contact Information
  
• List Drug(s) of choice
  
• Your Recovery Experience (check all that apply)
  

  Residential Treatment AA NA CA SMART

  Outpatient Treatment Medication Assisted SOS Self Physician

  Detox Harm Reduction Faith Based Mental Health

• Experiences that could strengthen the Coach/Recoveree relationship (check all that apply)
  

  Veteran Home Loss Anger Mgmt Volunteer

  Alcohol/Drug Courts Return to School Reading/Writing Leadership Roles

  Divorce Parent Hobbies Business/Ownership

  Job Loss Legal Involvement Outdoor Interest Grief Issues

• Experience with other systems of care (counseling, recovery supports, sober living houses, etc.)
  

• Do you have Transportation: Yes No

  How far are you willing to drive as a Recovery Coach: Choose 0 5 10 20 30 40 50 >50 miles

• Do you have;
  

  Phone Service: Yes No

  Internet Service: Yes No

  An Email Account: Yes No

• Have you ever been convicted of a crime,
  other than a misdemeanor or minor traffic offense?
  Yes No
• If yes, please provide full explanation including resolution of charges
  

• Do you speek more than one Language? Yes No

  If yes, list languages

• Education
  GED High School Some College Bachelor Degree Advanced Degree Other
• Other Specialized Training/Education
  

• Are you available 4 hours a week   to provide coaching services Yes No

  Would you be willing to provide peer   telephone support services for NMSAS Yes No

• What is your chief motivator for becoming a Peer Recovery Support Volunteer
  Be of Service to Others
  Learn and Grow
  Recognition
  Advocacy
  Multiple Pathways
  
  Please explain and list any other motivators
  
• 
  Is there anything else that you would like to tell us about yourself
  
• 
  Please list any special needs that you might have for the training sessions.
  e.g. food allergies, wheelchair accessable, etc.
  
• 
  Please tell us which training sessions you would like to attend.
  
• Questions about the application should be directed to Tory Werth, twerth@nmsas.org
  or Kelly Korson kkorson@nmsas.org or by calling NMSAS Recovery Center at 989-732-1791