Telephone Recovery Support Consent [cs_content][cs_element_section _id=”1″][cs_element_row _id=”2″][cs_element_column _id=”3″] Telephone Recovery Support Consent Name * Date of Birth * Phone * Refereed By Cell Phone Current Housing---Sober HouseHalfway HouseOther Address City Zip State Gender---MaleFemale Email Address Telephone Recovery Support calls are made between 9am and 6pm Eastern Time Monday thru Friday. Please select the time range that reflects when you would like to be called. 9am – NoonNoon – 2pm2pm – 4pm4pm – 6pm DO NOT LEAVE MESSAGE I understand and agree to the following: 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 Sign with your mouse [/cs_element_column][/cs_element_row][/cs_element_section][/cs_content]