Recovery Coach Academy Application Form

Recovery Coach Trainings Application

CARC Trainings - CCAR Curriculum

Facilitators Rich Hollett and Gianna Sandelli

Email*

example@example.com

Todays Date:*

Date

Full Name*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

DOB*

Referal Information (Name, Agency, etc.)

Please list your current employment information including: Company and/or Program, Position Title, Address/Location, Supervisor Role and Contact Information:

Have you received a GED or HS Diploma?

GEDHigh School DiplomaNo, I have not obtained either a GED or HS DiplomaOther

Referal Information Name Agency etc*

Please specify which training you are applying to attend (RCA or Ethical Considerations)

Recovery Coach Academy:Ethical Considerations:

Are you currently employed or volunteering as a Recovery Coach in Massachusetts?*

YesNo

If you answered yes; please list your Recovery Coach Supervisor information below (Supervisor name, Title, Company, contact information)

Is completing the RCA and/or working towards obtaining a CARC a requirement of your current employment or volunteering position?

YesNoOther

If you answered no to the previous question, please state why you are interested in taking the RCA:

Do you identify as a person in long-term recovery from a SUD?

YesNoOther

If yes; do you identify as having 2 or more years in long term recovery?

YesNoOther

If no; please identify how a SUD has affected you in your lifetime:

Please tell us a little about yourself, including strengths, experiences, etc. that has led you to applying to participate in the RCA (5-8 sentence maximum):

If you have been referred by someone to apply for this training, please list name and affiliation below: