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12 x 12 Recovery

a beacon of hope and support nestled in the heart of Concordia, Kansas.

Please complete the form to begin your journey to sober living.

First & Last Name

Phone Number

Email Address

DOB

Please select all that apply

Convicted of a Violent Crime

Convicted of a Fellony

On Corrections

Convicted of DUI or DWI

Sex Offender

On Parole

On Probation

Pending Charges

Currently Incarcerated

.

Able to Work

Cloud County Resident

Own a vehicle

Ever lived in a Sober Living Home

Compleated Detox

Willing to enrole in a Treatment Program

Use OTC or Prescription Drugs

Ever Overdosed

Ever Attempted suicide

Have Allergies

Seizures

AIDS/HIV+

Hepatitis A, B or C

Is there anything that you want to add?

Thanks for submitting!

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