NMSAS Peer Recovery Coach Application

• 
  Application Date
  

• First Name

  Middle Name

  Last Name

• Preferred Name / Nickname

  Date of Birth

• Street Address

  City

  Zip Code

• Phone Number

  Email Address

  County Choose Alcona Alpena Antrim Benzie Charlevoix Cheboygan Crawford Emmet Grand Traverse Iosco Kalkaska Leelanau Manistee Missaukee Montmorency Ogemaw Oscoda Otsego Presque Isle Roscommon Wexford

  You must reside in one of the Michigan counties listed in the dropdown to become a NMSAS Peer Recovery Coach.

• Gender: Man Woman Transgender Non-Binary Other

• Sobriety Date
  
• Person that referred you to NMSAS
  
• Emergency Contact Information
  
• How would you prefer that NMSAS staff contact you? (check all that apply)
  

  Text     Phone Call     Email

• List Drug(s) of choice
  
• Your Recovery Experience (check all that apply)
  

  Residential Treatment AA NA CA SMART

  Outpatient Treatment Medication Assisted SOS Self Physician

  Detox Harm Reduction Faith Based Mental Health

• Experiences that could strengthen the Coach/Recoveree relationship (check all that apply)
  

  Veteran Home Loss Anger Mgmt Volunteer

  Alcohol/Drug Courts Return to School Reading/Writing Leadership Roles

  Divorce Parent Hobbies Business/Ownership

  Job Loss Legal Involvement Outdoor Interest Grief Issues

• Experience with other systems of care (counseling, recovery supports, sober living houses, etc.)
  

• If religion is a meaningful part of your life, please tell us your affiliation (Optional)
  Amish Baptist Buddhist Catholic Congrgationalist Episcopalian	Greek Orthodox Hindu Jehovah's Witness Jewish Lutheran Mennonites	Methodist Mormon Muslim-Shia Muslim-Sunni Native American Religion Presbyterian	Quakers Reformed Restorationist Russian Orthodox Unaffiliated (Agnostic, Atheist, etc.) Other

• What mode of communication would prefer to use while coaching recoverees? (check all that apply)
  

  Texting     Phone Calls     Zoom Video Conference     In-Person

• Do you have Transportation: Yes No

  How far are you willing to drive as a Recovery Coach: Choose 0 5 10 20 30 40 50 >50 miles

• Do you have;
  

  Phone Service: Yes No

  Internet Service: Yes No

  An Email Account: Yes No

• Have you ever been convicted of a crime,
  other than a misdemeanor or minor traffic offense?
  Yes No
• If yes, please provide full explanation including resolution of charges
  

• Do you speak more than one Language? Yes No

  If yes, list languages

• Education
  GED High School Some College Bachelor Degree Advanced Degree Other
• Other Specialized Training/Education
  

• How often are you available to provide coaching services Choose 0 1 2 3 4 5 6 7 8 9 10 Hours Days / Week Month

  Would you be willing to provide peer   telephone support services for NMSAS Yes No

• What is your chief motivator for becoming a Peer Recovery Support Volunteer
  Be of Service to Others
  Learn and Grow
  Recognition
  Advocacy
  Multiple Pathways
  
  Please explain and list any other motivators
  
• 
  Is there anything else that you would like to tell us about yourself
  
• 
  Please list any special needs that you might have for the training sessions.
  e.g. food allergies, wheelchair accessable, etc.
  
• 
  Please tell us which training sessions you would like to attend.
  
• Questions about the application should be directed to Kelly Korson, kkorson@nmsas.org or Grayson Lewis, glewis@nmsas.org or by calling NMSAS Recovery Center at 989-732-1791