Member Name: Client first nameClient last name

Date of Original Approved Pass: Date

Original Pass Expiration Date/Time: Date

Requested Extension Date/Time: Date

Reason for Requesting Extension:
(Please provide detailed information about why you need additional time. Include specific circumstances or events prompting this request.)

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Triggers Encountered While on Pass and How They Have Been Handled Thus Far:
(Please list any triggers you have come into contact with during this pass and describe how you responded to them.)

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Goals for the Extended Time:
(Outline what you plan to accomplish during the extended time and how it supports your recovery journey.)

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2. Text field

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Why This Extension is Beneficial for Your Sobriety:
(Explain how the extension will positively impact your recovery and ongoing sobriety.)

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Resident Signature:
Signature

Date: Date

Once you complete the form, please press the green Submit button at the bottom of the screen to send it. This will notify ASHA of your request.

Once received, we will review your submission and notify you whether your request has been approved or denied. Providing detailed information in your request is essential, as it helps us assess whether an extension is appropriate.

Important: If the form is not submitted correctly, we will not receive your request, and no action will be taken. Please double-check that you’ve pressed the submit button to ensure successful submission.