SUD Group Participation Form

Full Name

First NameLast Name

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Emergency Contact Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Briefly describe your experience with substance use and recovery (optional)

Have you participated in a support group before?

What are your main goals for participating in this group? (Select all that apply)

Preferred Group Meeting Times (Select all that apply)