Expression of Interest & preferences for participating in future My Recovery programs

Complete the following questions to express your interest in participating in future My Recovery programs and your preferences for participating. We will contact you to confirm receipt and later to provide session dates / times and confirm your interest. Please note: If you are completing this form for someone else, it is expected that person has provided you with consent.

Name:*

Address:*

Phone:*

Email*

Why do you want to do the My Recovery program?*

select all that apply

What recovery skills or strengths would you like to develop?*

select all that apply

Communication
How to speak up for myself
Discovering my story
Other

Do you have someone who will support you through this program?*

Yes
No

If yes, why did you choose them?

I acknowledge that I am:*

select all that apply

Over 18
Living with mental health challenges or other related issues (trauma, alcohol and/or other drug issues)
On my own journey of recovery
Prepared to access support during the My Recovery program
Prepared and willing to commit to attending all 9 sessions of the program

Preferences for Participating

In the following questions you will be asked about your preferences for participating in future My Recovery programs. Please note: Each My Recovery program consists of 9 sessions, that are 3 to 3.5 hours long. Light refreshments will be provided during each session. There is no cost to attend.

I am available during the following windows to participate

select all that apply

I prefer to participate in a My Recovery program that is

select all that apply

one session per week (i.e. 9 week program)
two sessions per week (i.e. 4.5 week program)

I prefer to participate in a program located in

select all that apply

Darwin Northern Suburbs
Darwin City Region
Palmerston Region

I prefer to participate in

select all that apply

Women Only Program
Men Only Program
Program for Men and Women

I have the following additional preferences for my participation

(e.g. participation during school term, participation before/after specific dates, venue close to public transport.)

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