Thank you for your interest in Racing for Recovery. We offer a balanced holistic lifestyle of recovery to all persons affected by addiction. We understand the devastation drugs and alcohol have on self, family and communityand are proud of you to taking ACTION to improve your life.
Racing for Recovery offers an opportunity for those who are ready for an exciting, educational.rewarding and beneficial concept to utilize a program which focuses on healing from emotionaltrauma that lead to a choice to use drugs and alcohol.
Client referral source
Client referred by
Have you received services from us in the past?
Desired Date to Start Services: Date
General Contact Info:
First Name: Client first name
Last Name: Client last name
Address: Client Address
City: Client City
State: Client State
Zip: Client Zip
County: Text field
Email: Client email
Phone Number: Client phone
Client marital status
Do you have a photo ID?:
Do you have a current unrestricted driver’s license?
Are you currently employed?
Substances of Choice: Client substances of choice
Sobriety Date: Recovery history 1 sobriety date
Are You Currently in Treatment?
Most Recent Treatment Center Name: Treatment center 1 name
Treatment Admit Date? Treatment center 1 started
Treatment Discharge Date? Treatment center 1 ended
Reason for Discharge:
Where did you stay last night:
If in treatment or jail, do you have a safe sober place to stay when you leave?
Are you on any of the following MAT substances: Suboxone other than detox, Methadone, Bunavil,
Sublocade, Zubsolv, Vivitrol
Are you a registered sex offender?
Do you have any outstanding warrants?
Are you on probation?
If yes, what court(s)?
Name of Probation Officer(s)
Do you have any felony convictions?
If yes, what? Text field
Do you have any pending sentencing or possible jail time upcoming?
If yes, what is your court date? Date
Why, specifically, do you want to come to Racing for Recovery?
Once your form is submitted, we will contact you for scheduling.
By continuing, you agree that your electronic signature is the legally binding equivalent to yourhandwritten signature. Whenever you execute an electronic signature, it has the same validity andmeaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning ofyour electronic signature or claim that your electronic signature is not legally binding.
I attest that the above information is correct and subject to further background review.