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(216) 441-2496

Peer Recovery Form

Use the form below to apply for Peer Recovery.

Peer Recovery Services Application

First Name

Last Name

Company

Phone

Address

Recovery Journey Information: Do You Identify As?

Alcoholic

Drug Addict

Other/I Don't Know

CURRENTLY IN TREATMENT?

Yes

How do you plan on staying clean and sober?

Are you currently employed?

Yes

Actively Seeking Employment

I.O.P. is 9:00AM to 12:30PM on Monday thru Thursday and you are able to commit with your schedules?

Yes

List pending charges, cases and/or warrants:

On Probation/Parole?

Probation

Parole

Inactive Probation

No Parole/Probation

Probation/Parole Officer Name And Number:

Emergency Contact:

List of all medical and/or psychiatric conditions:

List all current medications:

Document(s) Upload: Please provide the following:

Are you on medically- assisted treatment?

Suboxone

Methadone

Vivitrol

None

First Name

Last Name

Relationship

Phone

Address

2.) Certification of Completion of Treatment

Upload File

Upload supported file (Max 15MB)

1.) Assesment

Upload File

Upload supported file (Max 15MB)

3.) Release of Information for other Care Providers (i.e., case managers, probation officers, counselors, etc.)

Upload File

Upload supported file (Max 15MB)

I agree to the terms & conditions: By checking this box, you agree to receive text messages from Jordan CRC related to (SMS Type) at the phone number provided above. You may reply STOP to opt-out at any time. Reply HELP for assistance. Messages and data rates may apply. Message frequency will vary. Learn more on our Privacy Policy Page and Terms & conditions.

Thanks for registering. See you there!

Empowering Female Survivors of Human Trafficking, Drug Addiction, Re-entry and Behavioral Health.

Email: info@jordan4change.com

Phone: (216) 441-2496

Donate: CLICK HERE

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