Ready for My Recovery Form

This form is confidential.

Submit your completed form and receive a My Recovery Journey backpack** filled with items and resources to support you in your recovery from substance misuse (excluding tobacco/nicotine use).

* Required Field

How did you find out about this program? If a provider, please name:

Today's Date (MMDDYYYY):

Your First Name: *

Your Last Name: *

Your Date of Birth (MMDDYYYY): *

Mailing Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Email:

Best day/time to reach you?:

Have you recently used substances (other than tobacco/nicotine) but are ready to take the first step in your recovery? Yes No

If you need immediate assistance with substance use, please call 2-1-1.

Note: Tobacco/nicotine use are not included as part of this program.

**Some restrictions and limitations apply. Each member can earn up to $250 in cash and non-cash goods and services through June 30 each year.