Intake form

Name *

Email address *

What is your current living situation?

What type of support are you seeking?

Please select at least one option.

Spiritual guidance

Addiction recovery

Mental health support

Community fellowship

Have you previously attended a recovery program?

What substances are you seeking recovery from?

Please select at least one option.

Alcohol

Drugs

Prescription medications

How did you hear about golden heart recovery ministries?

What is your preferred method of communication?

Please select at least one option.

Phone call

Text message

Email

In-person meeting

Are you currently involved in any other support groups or programs?

What are your spiritual beliefs or practices?

Which service or services are you interested in?

Please select at least one option.

Worship services

Bible studies

Support groups

Community Service/VolunteerIng

Additional questions or comments