H&I Questionnaire 2015 06 21
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.
Where do you live?
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.
Being aware and informed about it?
Possibly getting involved in H&I service locally?
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?
I don't know
Have you done any H&I service?
Yes, with CoDA
Yes, with another 12 Step group
Yes, with another type of organization
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 contract information below so we can get back to you individually.)
Inmate Sponsorship Program
Taking CoDA information into institutions
Helping start a meeting in an institution
Serving on the H&I international committee
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.)
Other professional area
Do you have any comments or questions about CoDA H&I Service?
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.
Name (First Name , Last Initial)
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