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Text for Recovery Enrollment
(Text for Recovery) Personal Concierge Enrollment
GomoWPAdmin
2021-02-01T16:33:09+00:00
Please fill out the information fields below on behalf of the caller to the best of your ability.
Do you live in Ocean County, NJ?
*
Yes
No
Are you 18 years of age or older?
*
Yes
No
This program is only available to residents of Ocean County, NJ who are 18 years of age or older.
Your Information
Name
*
First
Last
Mobile Number
*
Zip Code
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Are you a(n):
*
Individual in recovery
Loved one of someone in recovery
Are you interested in being linked directly to a Peer Recovery Specialist?
*
By clicking yes, you are agreeing to have your contact information sent over to a trained Peer Recovery Specialist. You will be contacted by a Peer Recovery Specialist within 24 hours of enrollment. If this is a medical emergency and you need immediate assistance, please call 911.
Yes
No
Please indicate your level of agreement or disagreement with the following statements
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I am confident of my ability to manage my recovery in my everyday life.
I have the appropriate support and resources to help me manage my recovery.
I am a happy and hopeful person.
Would you be interested in answering 2 additional questions to help us better serve you?
*
These questions/answers will not impact your enrollment.
Yes
No
Please answer these additional questions
What is your or your loved one’s drug of choice?
Choose all that apply.
Alcohol
Barbiturates (Amobarbital, Pentobarbital, Secobarbital, Etc.)
Benzodiazepine (Xanax, Klonopin, Valium, etc.)
Cocaine
Inhalants (Solvents, Aerosol Sprays, etc.)
Marijuana
Opiates (OxyContin/Vicodin, Heroin, Fentanyl, etc.)
Tobacco
Other
Are you or is your loved one in substance use treatment or service currently?
Choose all that apply.
DCP & P
Detox Facility
Half-Way House/Sober Living
Intensive Outpatient (IOP)
Justice Involved (Probation/Parole, Drug Court, PTI, NJ ReEntry, etc.)
MAT (Sub, Meth, Vivitrol)
Residential Facility
Self-Help/AA/NA/Peer Recovery Support
Additional Concerns
Please note any concerns or issues you would like to disclose.
Terms & Conditions
Please accept the Terms & Conditions below
*
The caller has accepted the
Terms & Conditions
for this program.
Δ
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