Telephone Recovery Support Consent

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Name *

Date of Birth *

Phone *

Refereed By

Cell Phone

Current Housing

Address

City

Zip

State

Gender

Email Address

Please select the time range that reflects when you would like to be called. 9am – NoonNoon – 2pm2pm – 4pm4pm – 6pm

DO NOT LEAVE MESSAGE

I grant permission for a volunteer from the Portland Recovery Community Center (PRCC) to call me weekly on the above telephone number(s) to support me in my recovery.
Each time the PRCC volunteer calls, he/she will be asking me how my recovery is progressing and if I am in need of additional support (i.e., meetings in area, recovery community centers, safe/sober housing, social events, other resources)
At the time of a call, if I am in need of a referral to a treatment program or detox unit, I will be assisted in finding a program, if I so desire.
At any time I may decide not to take part in this service, I will call PRCC at 1-207-553-2575 or tell the volunteer when he/she calls.

Date

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