H&I Questionnaire

You have signed up for the Hospitals and Institutions (H&I) email list. In an attempt to better understand who is signed up on this list, we ask you to respond to this simple short questionnaire. If you would like us to respond to you directly, please enter your contact information which is optional.

Please enter your zip code to help us know where you live. if you live outside of the United States, enter your country.

What is your interest in CoDA Hospitals and Institutions?

Check as many of the boxes below.

I want to learn how I can support H&I service: (Check all that apply)

Are there prisons, jails, shelters, treatment centers, in your area?

Have you done any H&I service?

Please check any of the following that you would be willing to do and like information about doing service in that area.

(If you check one or more of these, please include your contact information below so we can get back to you individually.)

If you are professionally involved in any of the following areas, please check the box(es) below.

(Check all that apply to your.)

(Please specify in comments.)

Are you actively attending CoDA meetings?

Optional contact information

If you want us to contact you, please fill in this information. Our preferred method of correspondence is via email.

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May we share your contact informationn?

Do we have permission to share your contact information with other H&I trusted servants and local facilities looking for people to do service work within their institution?

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