Sobriety Story Interview Release Form
Please complete this form to share your sobriety story and grant permission for interview and publication.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you at least 18 years old?
*
Yes
No
Preferred Pronouns
Please Select
She/Her
He/Him
They/Them
Other
How would you like your name to appear if your story is published?
*
Please provide a brief summary of your sobriety story or key points you wish to share in the interview.
*
May we record your interview (audio and/or video)?
*
Yes, audio and video
Yes, audio only
No
Do you consent to your sobriety story being published or shared (e.g., website, social media, print)?
*
Yes, with my name as provided
Yes, anonymously
No
Emergency Contact Name and Phone Number (optional)
Signature
*
Submit Release
Submit Release
Should be Empty: