Recovery Coach Application

Personal Information

Fields marked with an * are required

Today's Date *

Full Name: *

Address: *

City, State, Zip Code: *

Email: *

Home Phone (optional):

Work Phone

Cell Phone:

Birthdate: *

Current Employer and Occupation: *

Emergency Contact Name: *

Emergency Contact Number: *

Do you have access to transportation, other than public transportation, to get to and from volunteer work?: *

Yes
No

Please list all availability below:

(Hours to meet with walk-in participants are 8am-5pm M-F. Follow up contact and continued coaching is scheduled by the coach and participant.)

Hours Available *

Morning
Afternooon
Evening

Specify hours (optional):

Recovery 1 of 2

Fields marked with an * are required

Are you in Recovery?: *

Yes
No

If yes, how long?:

Do you have a close family member in recovery?: *

Yes
No

Do you abstain from the use of alcohol and other drugs? *

Yes
No

What is your definition of recovery?: *

Why do you want to become a Recovery Coach?: *

What strengths do you think you would bring to the role of a Recovery Coach?: *

Do you participate in any programs or activities to support your recovery? Please describe: *

Do you have any previous experience volunteering with, mentoring or sponsoring those with a substance use disorder? Please describe: *

Recovery 2 of 2

Why would a person who has just been revived with Narcan want to listen to what you have to say?:

Do you have any questions/concerns/expectations about the role of a Recovery Coach?:

Do you speak any languages other than English? If so please specify language & fluency:

Please list three (3) personal or job related references: Name, Email, Phone

Background Check

Fields marked with an * are required

Have you ever had an allegation of child abuse or neglect substantiated against you? *

Yes
No

Have you ever been convicted of a crime? *

Yes
No

If yes, please describe offense, indicating date of convictions, jurisdiction and penalty imposed:

Are you currently on probation?: *

Yes
No

If yes, list Probation officer name/phone#

Are you currently on Drug Court: *

Yes
No

If no, list if you are a graduate and the date graduated:

If selected to become a certified Recovery Coach, your duties as a volunteer will place you in close personal contact with persons requesting assistance with substance use disorders and recovery. This may create circumstances in which you will interact with the public, fellow volunteers, medical professionals, law enforcement personnel and treatment providers. In addition, you may be granted access to law enforcement facilities and sensitive information. For these reasons, the Center for Prevention & Counseling has an obligation to help ensure the safety of program participants, volunteers and members of the public the Recovery Coach may come into contact with.

In connection with an individual’s application to be considered for training as a Recovery Coach with the Center for Prevention & Counseling, the Newton Police Department will fingerprint each applicant being considered and will conduct a review of their criminal history and probation status to determine suitability for program participation.

The Center for Prevention & Counseling, in collaboration with the Newton Police Department, recognizes that people make mistakes and are capable of change; therefore, IT IS IMPORTANT TO NOTE THAT PREVIOUS CRIMINAL CONVICTIONS OR CONDUCT WILL NOT NECESSARILY DISQUALIFY APPLICANTS FROM BEING SELECTED TO PARTICIPATE IN RECOVERY COACH ACADEMY. All circumstances will be considered in making a decision regarding your application.

In instances in which the applicant is deemed not appropriate to for the training, efforts will be made to find other roles and duties which will allow the applicant to participate in and support the program.

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I verify the above information is true and understand any false information is grounds for denying my request.

I acknowledge and understand that I will be fingerprinted and the Newton Police Department will conduct a review of my criminal history and probation status and report this information to The Center for Prevention & Counseling to determine suitability for program participation and any such responsive information will not necessarily disqualify me.

I hereby release from liability and agree to hold harmless, under any and all possible cause of legal action, including negligence, the Center for Prevention & Counseling, the Newton Police Department, and any of its officers, agents or employees for any neglect or wrongful statements, acts, omissions made or recorded in the course of my background query.

Having completed the above application form and read the Background Information Query process, I hereby request to be considered to participate in the Recovery Coaching Academy. By clicking submit you are Electronically Signing:

Successful submissions will receive confirmation.

Personal Information

Recovery 1 of 2

Recovery 2 of 2

Background Check