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
Your Interests or Hobbies (check all that apply)
Sports
AA
hunting-fishing
Exercise
Outdoor activities
Winter activities
Nature
Volunteering
Cars
Motorcycles
TV
Movies
Social Media
Travelling
Gardening
Gaming
Writing
Arts-Crafts
Working with elders
Reading
Cooking
Comedy
Working with children
Caregiving
Socializing
Making music
Listening to music
Woodworking
Animals
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
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
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 types of activities would you volunteer to do? (check all that apply)
Face to Face Coaching
Phone or Video Call Coaching
Information tables at events
Event Planning
Becoming a Trainer
Technical Help
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 Tobias Neal,
tneal@nmsas.org
or by calling NMSAS Recovery Center at 989-732-1791