Recovery Coach Application Form

Please send us an email should you wish to be notified of future trainings.

Please use this application form for the Recovery Coach Training Academy of the Kennebunks. Please complete all fields. Required fields have a red asterik. We will review your application and notify you of your status with in 10 business days.

Note: Scholarships are available for York County Residents. Tuition for other counties is $300.00.

Phone

First Name *

Last Name *

Address *

Address 1

City *

State/Province *

Postal Code

Email Address *

Email Confirm *

Home Phone

Mobile Phone

Age

Birthday

xx/xx/xxxx

Race

Race
White/Non Hispanic Afro American/Black Latino/Hispanic American Indian Alaskan Hawaiian/Non Pacific Islander

Gender

Gender
Male Female Transgender

Residence

Residence
Rent Own Family Friends Couch Surf Shelter Homeless

Education

Education
Enter last grade completed

Recovery Information

Recovery Status

Recovery Status
In Recovery Not in Rcovery

Recovery Path

Recovery Path

Abstinence

MAT & 12 Step

Medication Assisted TX - Suboxone

Medication Assisted TX - Methadone

Family Member

First Responder

Concerned Citizen

Recovery Capital

Employment Status

Full Time

Part time

None

Education Status

Full time Student

Part time Student

Not Attending

Essay

Essay
500 Words on Why You Want to Be a Recovery Coach

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