Addiction Treatment & Recovery Coaching | Sober Coach Adam

First & Last Name

Email address

Can Sober Coach Adam contact you via email? *

Yes

Phone number

Can Sober Coach Adam contact you at the number provided above? *

Yes

If you've answered yes above, can we leave a voicemail? *

Yes

Pronouns

Birthdate

Sobriety Date (if applicable)

Presently living with

Please indicate all current treatment and/or supports you are receiving for your substance use. Indicate all that apply.

Outpatient treatment

Inpatient treatment

Withdrawal Management and/or Medical Detoxification

Psychiatrist

Psychologist

Psychotherapist

Family Doctor

Hospitalization

Sober/Recovery Living Facility

Peer-Support/Recovery Groups/Meetings

Other:

What are the motivating factors for booking your discovery call with Sober Coach Adam?

What are your motivating factors for working with a Recovery Coach/Companion?

Please describe your current situation as it relates to your use / or recovery.

Is there anything else you'd like to share about yourself to help inform our call?

Are there any specific questions you would like answered on the call?

Thank You!

Your form has been successfully submitted.

Sober Coach Adam will review your information and get in touch with you soon.

We appreciate you taking the time to share your story.

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One Goal at A Time!

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