Name *

First Name

Last Name

Phone *

(###)

###

####

Recovery Stage *

If you are familiar with the four stages of recovery, please select the one that most accurately describes you

Overwhelmed

Struggling

Living with

Living beyond

I am not sure

Personal Action *

The AIR Support Group focuses on taking personal action in recovery. With this in mind, please check all that apply

I believe personal effort can positively affect my recovery.

I would be willing to write a list of goals and share them with the group.

I have spent time reflecting on my thoughts.

I have written my thoughts in a journal.

I would be willing to journal on a regular basis.

I would consider co-facilitating a group in the future if asked.

Contact Preference *

Thanks for your interest in joining the AIR Support Group. Someone will contact you shortly. What is the best way to get in touch with you?

Email

Phone