ARSC Peer Intake Form

226 Alcovy St, Building D, Monroe, Ga 30655

770-266-6788
We Lead with Support, We Leave with Empowerment

Peer Agreement
In the true definition of LEAD WITH SUPPORT, we would appreciate it if each Peer would commit to supporting their Recoveru services in the following:
- Agree to treat everyone, always, with dignity and respect
- Agree to be present each day, every week, that you are scheduled for transportation services, groups, and all scheduled 1:1 recovery services, unless prior arrangements have been made with your recovery coach and/or staff
- Agree to be on time and to remain throughout the entire group, session, or meeting
- Agree to participate in your own recovery by practicing honesty so your recovery coach can support you right where you are at
- Agree to put feelings into words, rather than inappropriate actions
- Agree to protect the names, identities, and personal information of fellow peers when discussing what is happening in the group
- Agree to smile, laugh, and have fun in your recovery
I acknowledge receipt of the above agreement. I will make a diligent commitment to have mutuality and agree to practice LEAD WITH SUPPORT.
Peer Intake Form
Peers Name

First NameMiddle NameLast Name
Peers Preferred First & Last Name
Personal Pronouns

Other
Date of Birth

MonthDayYear
Date
Social Security #
Do you have a phone number?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Homeless
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race
Ethnicity
Primary Language
Veteran Status
Gender
Sexual Orientation
Emergency Contact
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Permission to Contact
Insurance Information
Type
Provider
Group ID
Member ID
Family Status/Involvement
Do you have Children
Number of Children
Custody Status
Pregnant?
Due Date

MonthDayYear
Date
DFCS Involved?
Legal Status
Currently Incarcerated?
Probation/Parole?
Supervising County
Supervising Officers Name
Awaiting Court?
Next Court Date

MonthDayYear
Date
Are you receiving services from any of the following?

Other
Substance Misuse History
Substance of Use

Other
Date of Last Use

MonthDayYear
Date
Have you overdosed?
If yes, number of times
Have you used Narcan?
If yes, number of times
General Information
What brought you here?
Have you engaged with this type of service before?
On a scale of 1-5 (5=excellent, 1=poor) How would you rate your emotional state?
How can we support you moving forward?
Is there anything else you would like to share?
File Upload

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Transportation Service Waiver
Please read this form in its entirety and be aware that in consideration for Walton Empowers, INC. Transportation Services, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injured, damages, or loss which you might sustain as a result of said services, including but not limited to, vehicle operations and boarding and exiting the vehicle.

I recognize and acknowledge that Walton Empowers, INC. is neither a common carrier nor in the business of providing transportation to the public. I further recognize and acknowledge that there are certain risks of physical injury to vehicle passengers, and I voluntarily agree to assume the full risk of all injuries, damages, or loss, regardless of severity, that I may sustain as a result of participation in any and all activities connected with or associated with receiving transportation services, including but not limited to injuries, damages, and loss arising out of negligent operation or supervision of the vehicle. I further agree to waive and relinquish all claims I may have (or accrue to me) against Walton Empowers, INC. including its respective official, agents, volunteers, and employees (hereinafter collectively referred to as "Party").

I do hereby fully release and forever discharge the Party from any and all claims for injuries, damages or loss that I may have, which may accrue to me arising out of, or in any way associated with said transportation services.

I further agree that this agreement shall be governed by the State of Georgia.
I have read and fully understand the above waiver and release all claims.
Printed Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

226 Alcovy St, Building D, Monroe, Ga 30655

We Lead with Support, We Leave with Empowerment

Peer Intake Form

Emergency Contact

Insurance Information

Family Status/Involvement

Legal Status

Substance Misuse History

General Information

Transportation Service Waiver