Let’s get started today!

Are you ready to get started on the road to recovery? Let’s get started. Please answer with as much information as possible and as truthfully as possible. All information acquired here is confidential and will only be viewed by Recovery In Action staff in order to get you started on your journey ASAP.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Do you receive Medi-Cal?

Yes

No

Medi-Cal Number

(Optional)

Date

Date Of Birth

MM

DD

YYYY

Emergency contact

First Name

Last Name

Phone

(###)

###

####

Have you been convicted of any sexual crimes?

yes

no

Arson?

yes

no

Do you have any severe or untreated physical health problems

yes

no

Substance of choice (last 12 months)

Last date used

MM

DD

YYYY