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